Unveiling Sexsomnia: An In-Depth Exploration

Sexsomnia is one type of parasomnia that can negatively impact the quality of life for individuals affected and potentially lead to legal complications. The growing prevalence of sexsomnia demands attention due to the widespread misinformation and the misconception that it is not a medical issue. This review will delve deeper into sexsomnia, including its diagnosis and management. Parasomnia refers to undesired physical events or experiences that occur during various stages of sleep. Sexsomnia, a form of parasomnia associated with non-rapid eye movement (NREM) sleep, is characterized by unconscious, abnormal sexual behavior. Sexsomnia can manifest during any sleep phase but is most frequently observed during NREM sleep. Clinical manifestations of sexsomnia include vocalizations, fondling, kissing, masturbation, and even engaging in sexual intercourse without recollection upon waking. A comprehensive evaluation, including a thorough medical history and additional investigations such as polysomnography with electroencephalography, aids in establishing a diagnosis of sexsomnia. Presently, there is no definitive treatment for sexsomnia. Management approaches involve non-pharmacological and pharmacological. Sexsomnia, if not recognized as early as possible, can have detrimental effects on both the affected individual and the surrounding environment. Lack of awareness about sexsomnia and hesitation to seek treatment contribute to the lack of information about its prevalence. In-depth knowledge is crucial for accurate diagnosis and determining the appropriate management strategies for this condition. Further research is needed to determine sexsomnia and its management.


Introduction
Sexsomnia is a type of parasomnia, a disorder of abnormal sleeping behavior.Growing evidence of sexsomnia needs to be a concern because it can reduce the sufferer's quality of life. 1 The lack of awareness regarding sexsomnia as a medical condition and the hesitancy of individuals to seek therapeutic assistance contribute to the scarcity of information about its prevalence in the general population. 2 Consequently, it is crucial to address this issue given its potential to significantly impact the quality of life for those affected. 1This review aims to shed light on the risk factors and diagnostic approaches associated with sexsomnia while also exploring potential management strategies for the future.

Review
Parasomnias encompass a range of undesired physical events or experiences that occur during the process of falling asleep, during sleep, or upon awakening. 3These conditions involve various manifestations, such as dreams, distorted perceptions, dysphoric emotions, abnormal movements and behaviours during sleep, and dysregulation of the autonomic nervous system. 4he International Classification of Sleep Disorders (ICSD) provides a comprehensive classification of parasomnias, which can be grouped into three main clusters: non-rapid eye movement (NREM)related, rapid eye movement (REM)-related, and other types, as outlined in Table 1.

Table 1. Classification of parasomnias 3
Sexsomnia, a clinical subtype of confusional arousal, is a sleep-related condition characterized by abnormal sexual behavior occurring without the individual's awareness. 5These episodes can involve a range of behaviours, including vocalizations, fondling, kissing, masturbation, sexual assault, attempted intercourse, and even complete sexual intercourse, with no recollection upon awakening.The most commonly observed behaviours during sexsomnia events are sexual intercourse and fondling. 6Typically, these episodes last for less than 30 minutes and occur suddenly.
The exact prevalence of sexsomnia remains uncertain; however, a research conducted in Norway provided estimates for both the lifetime and current prevalence of sexual behaviours during sleep, which were reported as 7.1% and 2.7%, respectively. 7Furthermore, it is noteworthy that sexsomnia tends to occur more frequently among males. 8

Risk Factors of Sexsomnia
The occurrence of sexsomnia involves a complex interplay of predisposing, priming, and precipitation factors, as depicted in Figure 1.Genetic factors are known to influence the incidence of parasomnias, with a higher prevalence of HLA B1*05:01 and HLA DQB1*04 observed in NREM parasomnias. 8Individuals with a family history of parasomnias exhibit an increased prevalence of similar parasomnias.syndrome, and periodic limb movements, contribute to the development of sexsomnia. 6dditionally, certain conditions such as sleepdisordered breathing and exposure to external noises can precipitate the occurrence of sexsomnia.

Pathophysiology of Sexsomnia
During the sleep cycle, an individual experiences two alternating phases: REM and NREM phases.The NREM phase can be further divided into four distinct stages known as N1, N2, N3, and N4.The N1 stage represents the transition between wakefulness and sleep, lasting approximately 3 to 5 minutes.It is characterized by closed eyelids, reduced muscle tone, and noticeable eye movement in both horizontal directions.As the individual progresses to the N2 stage, eye movement ceases, muscle tone remains diminished, and sleep becomes deeper compared to the previous stage.The N3 stage signifies an even deeper level of sleep compared to the stages.Finally, in the stage, the sleep is at its deepest, and the person becomes more difficult to awaken. 9he progression from one sleep stage to another is not immediate but involves a reorganization and transition of different neural centers before reaching a distinct point of noticeable manifestation.While sexsomnia commonly occurs during the slow-wave sleep phase (N3), it can also manifest during the N2 phase. 10To gain insight into the underlying mechanisms of sexsomnia, it is beneficial to examine the pathophysiology of NREM parasomnias, which involves factors such as sleep state instability, sleep inertia, and dissociated states. 11,12A comprehensive understanding of these processes can aid in comprehending the pathophysiology of sexsomnia (Figure 2).

Sleep state instability
This condition is considered to be the initial stage of NREM parasomnia.Within the NREM sleep phase, there is a physiological component known as the cyclic alternating pattern (CAP), which is functionally associated with oscillations of arousal and serves as a measure of NREM sleep instability.Multiple studies have demonstrated an elevated CAP rate during the N3 sleep phase. 13,14n analysis of electroencephalographic (EEG) data reveals that the frequency of awakenings from sleep increases during the N3 sleep phase.These findings support the notion of instability emerging during the NREM sleep phase, characterized by recurrent arousals, which are believed to be the triggering factor for confusional arousals.

Sleep inertia
This situation is characterized by the experience of awakening from incomplete sleep.The process of transitioning from sleep to wakefulness occurs gradually.When abruptly awakened from the NREM sleep phase, there is a decrease in cerebral blood flow compared to the pre-sleep state.However, within a span of 15 minutes, the cerebral blood flow gradually increases, leading to an enhancement in the level of alertness.

Dissociated state
The dissociated state refers to the brain's ability to simultaneously exhibit both sleep and wakefulness by deactivating higher cognitive regions in the central nervous system's motor pathway during the stimulation phase.Local frequency activation signifies a sudden interruption of the slow wave pattern in the motor cortex, accompanied by the presence of alpha waves and/or beta rhythms.Concurrently, there is an increase in slow waves observed in the dorsolateral prefrontal cortex, indicating the coexistence of sleep and wakefulness.

Diagnosing Sexsomnia
Prior to confirming the diagnosis of sexsomnia, healthcare practitioners should conduct thorough history taking and perform additional assessments.

History Taking
History taking must include sleep history, underlying medical history, family history, history of substance abuse, and current medications. 16leep history should screen for past and current sleep pathologies. 6It is important to rule out other possible diagnoses such as other sleep disorders, nocturnal seizure disorder, paraphilias, and the possibility of secondary gain, malingering. 16ble 2. Criteria for Sexsomnia 3,17

Physical Examination
It is commonly observed that the physical examination outcomes generally do not reveal any distinct irregularities.Numerous instances of sexsomnia have indicated the presence of obesity. 6,18

Additional Examination
The polysomnography results in sexsomnia cases demonstrated a notably elevated frequency of awakenings occurring during the N3 stage, also known as slow-wave sleep.According to the study conducted by Dubessy et al., it was observed that eight out of the patients (equivalent to 47%) experienced abnormal partial awakenings, accompanied by dissociated activities on EEG channels during at least one N3 awakening. 19These abnormal activities included: (1) A continuous slow delta rhythm on the frontal left and right channels contrasting with the rapid alpha rhythm on the posterior channels.(2) Concomitant, superimposed slow (θ/δ) and rapid (α) rhythms on all channels.(3) Diffuse slow (δ or θ) rhythm contrasting with sustained motor activity.Moreover, the utilization of EEG (electroencephalography) in examining the behavioral patterns of individuals suspected of having sexsomnia during sleep is also possible.The EEG recordings during a sexsomnia episode can reveal a dissociative pattern that frequently resembles a seizure-like activity.

Management of Sexsomnia
Due to the lack of a comprehensive understanding regarding the mechanism of sexsomnia, explicit treatment options were previously unavailable.However, recent advancements have provided some guidance in managing sexsomnia cases within the broader scope of parasomnia management.This includes the implementation of both non-pharmacological and pharmacological strategies.

Non-pharmacological approach -Patient Education
Comprehensive patient education for individuals with sexsomnia should encompass the potential legal implications that may arise in their interactions with sleeping partners.Additionally, it should incorporate guidance on practicing good sleep hygiene, implementing effective sleep management techniques, abstaining from alcohol and other substances, and creating an optimal sleep environment. 6sychotherapy Psychotherapy has demonstrated potential efficacy in treating various NREM parasomnias, including sexsomnia.Rahmatullah et al. discovered that cognitive behavioral therapy (CBT) shows promise in reducing symptoms associated with sexsomnia.Moreover, Contreras et al. highlighted the effectiveness of hypnosis as a therapeutic approach for managing sexsomnia. 20Notably, one advantage of hypnotherapy over CBT is its shorter duration, typically requiring only 1 to 6 sessions, while CBT necessitates a longer treatment period.
-Continuous positive airway pressure (CPAP) According to Contreras et al., the application of CPAP at a pressure of 8 cmH2O has been shown to effectively manage both breathingrelated sleep issues and instances of masturbation occurring during NREM sleep. 20Additionally, Muza et al. highlighted the utility of CPAP in alleviating symptoms associated with sexsomnia in patients. 21

Pharmacological Approach
To date, there is no specific pharmaceutical intervention designed specifically for the treatment of sexsomnia.However, several case reports have suggested the potential usefulness of clonazepam at a dosage range of 0.5-1 mg in managing sexsomnia. 6,21Furthermore, the administration of paroxetine at a dosage of 5-10 mg has been shown to enhance slow-wave sleep and reduce instances of sleep disturbances, although it may lead to side effects such as erectile dysfunction. 22Other medications, including trimipramine, lamotrigine, olanzapine, carbamazepine, clomipramine, fluoxetine, escitalopram, and duloxetine, have also been employed with limited success rates. 21,22

Summary
Lack of awareness about sexsomnia and hesitation to seek treatment contribute to the lack of information about its prevalence.From this literature, we can conclude that sexsomnia occurs during slow-wave sleep N3 but can also manifest during N2.The prevalence of sexsomnia itself is still not known for certain, but it occurs more often in men.This condition includes a complex group of genetic, priming and precipitating factors.Diagnosis includes a thorough history, physical examination, and polysomnography.Until now, there is still no specific treatment for cases of sexsomnia.Treatment for sexsomnia includes nonpharmacological and pharmacological approaches.Further research is needed to determine sexsomnia and its management.

Figure 1 .
Figure 1.Factors that increased the incidence of sexsomnia.