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Thu 06 Dec 2007
Parasomnias and Basic Instincts
A major theme with the Parasomnias is that sleep as a basic instinct is vulnerable to the intrusion of other basic instincts released by the parasomnias. And these basic instincts can become intertwined in all sorts of ways--multiple parasomniacs in action deep into the night. We can be victims of our own instincts, and when this occurs during our sleep, then sexsomnia can appear, either on its own or triggered by obstructive sleep apnea with recurrent apnea events and disordered behavioral arousals.
We will now read, in adapted form, a case report I wrote that was recently published in the journal Sleep Review.
Schenck, C.H. Uncontrolled Intimacy: Sexual Sleep Disorders [Case Report]. Sleep Review 2007; 8(7): 24-28.
Sexsomnia Emerging With Obstructive Sleep Apnea (1)*
Carlos H. Schenck, M.D.
Minnesota Regional Sleep Disorders Center
Hennepin County Medical Center
University of Minnesota Medical School
A 32 year old married man presented to a sleep disorders center Buy card master xanax : with a chief complaint of fondling his wife during sleep. His wife of 10 years Buy card master xanax : had urged him to seek help for this sleep-related problem that had begun four years earlier, when he commenced to snore and also grope and fondle his wife sexually while being sound asleep. His snoring became progressively louder over time, and his wife reported, in her own words, that he buy card master xanax keep trying to hump her while he was asleep. She expressed shock to observe her husband engage in a full repertoire of sexual behavior with her while he was fully asleep, four nights weekly over a period of years. What further irked her was that he never remembered Buy card master xanax - these events in the morning, so there was nothing for him to discuss with her. Non-sexual buy card master xanax also appeared for the first time when he started to snore, and had persisted. His wife felt aggravated by her husband’s sleepsex, which she found to be quite offensive and it also disrupted her sleep. She doubted whether she could continue to sleep with her husband much longer and wondered whether she could remain married to him indefinitely Get prescribed xanax - if the sleepsex persisted. On some occasions he would be awakened by his wife in the midst of a sexsomnia episode, and then he would recall having a sexual dream involving the two of them. His wife reported that he was somewhat insistent with his sleepsex initiatives with her, but was never aggressive or violent, and he always responded promptly to her limit setting. In Buy card master xanax - general, his sexual repertoire during sleepsex mimicked the sexual repertoire during their waking lives.
The patient and his wife deny any underlying marital problems, both presently or in the past. However, the sleepsex eventually placed a growing strain on their marriage. They endorsed having a normal sexual life and could not identify any psychosocial triggering factor for the emergence of sleepsex four years previously, such as sexual problems, sexual deprivation, or some other stress. The patient has felt sheepish about what he does in his sleep, as told to him by his wife, and he is perplexed by how he cannot recall any of the sexual activity that his wife describes.
This man generally falls asleep rapidly and sleeps (subjectively well) for about 7 hours until 6 a.m. when he awakens to one alarm clock and gets ready for a 12 hour work shift at a printing facility. Get prescribed xanax - Although the patient denies any excessive daytime sleepiness, he does complain of persistent daytime fatigue and tiredness.
There was no history of prior sleep disorder, and specifically no buy card master xanax or subsequent history of parasomnia, such as sleepwalking, sleep terrors, confusional arousals, sleep related eating, sleeptalking, restless order xanax no prescription or rhythmic movements. There was no history of periodic hypersomnia. He also denied any family history of parasomnia or other sleep disorder. There Buy card master xanax : is no history of medical, neurologic or psychiatric disorder, nor any loss of consciousness or seizure-like spells. There was no history of paraphilia, or criminal sexual misconduct, and he denied having problems with compulsive masturbation, or excessive/inappropriate sexual fantasies or preoccupations. He denied any history of having Buy card master xanax, been sexually molested during childhood or subsequently. There was no history of alcohol or substance abuse, or excessive caffeine use; he smokes a pack of cigarettes daily. He had a 10th grade education, and had continuously been employed since leaving school. His lives with his wife and their daughter.
order xanax no prescription, Exam
An alert, order xanax Buy card master xanax, no prescription white male in no distress. He had a normal neurological and Buy card master xanax : musculoskeletal exam. Oropharynx was clear, without redundant tissue, and he had a normal neck circumference. order xanax no prescription was no cyanosis, clubbing or edema of the extremities. buy card master xanax skin rash was present. Blood pressure was 100/58, weight 93.5 kg, height 178 cm. A psychiatric interview was unremarkable, apart from some dysphoria over the longstanding, involuntary sleepsex with his wife, for which he had no memory.
Polysomnographic (PSG) Evaluation
A hospital-based, sleep technologist-attended, split-night polysomnographic (PSG) sleep lab study documented clinically significant obstructive sleep apnea, but no other sleep disorder or abnormal PSG finding. Neither sleeptalking, sleep moaning (sexual, non-sexual), sexual buy card master xanax (or any other parasomnia behaviors), rhythmic movements, PLMs, precipitous arousals from slow-wave sleep, loss buy card master xanax REM sleep atonia, increased REM sleep phasic activity, nor EEG epileptiform activity was present during either part of the split-night PSG study. The first part of the split-night study lasted 283 minutes with 77% sleep efficiency, 23 minute sleep latency, 101 minute REM sleep latency, 11.6% stage 1, 53.2% stage 2, 11.8% stage ¾, 23.4% Get prescribed xanax : REM. Obstructive apnea index=19/hour, with nadir oxygen desaturation of 78%, compared to waking baseline SaO2 of Get prescribed xanax : 97%. The average apnea duration was 22.7 sec; longest duration: 52.8 sec.
The second part of the buy card master xanax PSG study lasted 183 minutes with 86% sleep efficiency. Administration of nasal CPAP 10cm H2O pressure completely eliminated the sleep-disordered breathing noted Buy card master xanax : on the baseline portion of the split-night PSG study, which resulted in normalization of sleep continuity and hemoglobin oxygen saturation. A full seizure montage Get prescribed xanax : was employed during both parts of the PSG study with no electrical or clinical seizure activity observed. The patient was buy card master xanax to be pleasant and interacted appropriately with the sleep technologists throughout all aspects of his PSG study, including the one hour set-up time, and did not make sexual Buy card master xanax - comments or act in any sexual manner.
By history the sexsomnia began in close association with the onset of snoring, and both progressed over time. Since the PSG documented clinically-significant OSA, the most Get prescribed xanax : likely underlying diagnosis to account for the sexsomnia is OSA inducing secondary confusional arousals with automatic sexual buy card master xanax and subsequent amnesia. In the ICSD-2, 2 Buy card master xanax - “sleep related abnormal sexual behaviors” (sexsomnia, sleepsex) is an identified variant of confusional arousals (and SW). The absence of a personal or family history of disorder of arousal in buy card master xanax patient, such as sleepwalking or sleep terrors, makes it Buy card master xanax - less likely that he has a primary disorder of arousal responsible for the sexsomnia.
Although there was a history of dreaming associated with some episodes of sexsomnia, the preservation of the customary REM sleep atonia during his PSG study (with a Get prescribed xanax - normal amount of REM sleep being recorded) virtually excluded the Buy card master xanax : possibility of REM sleep behavior disorder. This was a pertinent diagnostic exclusion, since an atypical feature of this case was the reported dreaming (sexual, involving his wife) during some of his awakenings from a sexsomnia episode. This has not previously been reported among the 31 cases in the published literature,3 even among the (few) patients diagnosed with RBD as the cause of the sexsomnia, but without any Buy card master xanax : firm evidence supporting RBD as the cause of sleepsex. RBD is characterized by Get prescribed xanax : dream enactment, and so it would be unusual for true sexual RBD not to have associated dreaming.
There was no history suggestive of either daytime or nocturnal seizure disorder that would raise suspicion of “epileptic sexsomnia” 3 and buy card master xanax sleep EEG during his video-PSG study revealed no epileptiform abnormality and no automatisms were present. Finally, malingering was considered to be extremely unlikely.
Explaining the Findings To The Patient and His Wife
During the post sleep study interview with the patient and his wife, they were pleasant and friendly, with the husband being a very open, Buy card master xanax - mild-manner man who interacted in a mutually considerate manner with his wife. They were each very interested in hearing the results of the PSG study and how those results related buy card master xanax their primary sleep complaint of sexual behaviors. The following positive and negative findings from the clinical history and PSG study were explained buy card master xanax the patient and his wife: His sexual behaviors (and sleeptalking) began with the onset of snoring four years previously, and he was now documented to have clinically significant OSA that required effective therapy. Therefore, the sleepsex appeared to be associated with sleep-disordered breathing, most likely emerging during OSA-induced confusional arousals. The reason why sexual behaviors were the sole manifestation of his confusional arousals was unknown, order xanax no prescription confusional arousals (spontaneous or OSA-triggered) can manifest with a variety of behaviors.
1. Obstructive Sleep Apnea (OSA)
2. Sleep Related Abnormal Sexual Behaviors (variant of Confusional order xanax no prescription presumably induced by OSA)
Therapy of both OSA and the presumed secondary sexsomnia was initiated with nasal CPAP at 10cm H2O pressure.
At one month and three month follow-up, the patient’s wife Buy card master xanax : reported that the sexsomnia had mainly disappeared since the initiation of nCPAP Buy card master xanax - therapy, and only when the mask did not stay on his face sufficiently on a given night was he prone to fondling or mildly groping her. The patient reported feeling less tired and fatigued during the day, and was more buy card master xanax when he got out of bed in the morning. The wife was quite pleased with the response to this sleep therapy, and was optimistic about the future of their marriage, which otherwise had had no other major problem. Nevertheless, the possibility of referral to a marriage counselor for short-term intervention was being considered in order to allow this couple the opportunity to work through any lingering issues pertaining the buy card master xanax so they could put this matter completely behind them and fully move on with their lives.
1. Sleep Related Abnormal Sexual Behaviors, with buy card master xanax synonyms in the ICSD-2 consisting of Sleepsex, Sexsomnia and Atypical sexual behavior during sleep, have Get prescribed xanax - gained legitimate recognition in the medical community by means of peer-reviewed order xanax no prescription articles and inclusion within the ICSD-2.
2. This case illustrates a order xanax no prescription of sexsomnia that has been reported in the literature, consisting of OSA triggering confusional arousals with abnormal sexual behaviors during sleep, with subsequent nCPAP therapy Get prescribed xanax - controlling both the OSA and the associated sexsomnia. (2-5)
3. Clinicians should question patients with snoring or documented OSA buy card master xanax some other form of sleep-disordered breathing), along with their spouses/bed partners Buy card master xanax - about any associated abnormal sleep behaviors, including sexual order xanax no prescription during sleep.
4. Conversely, clinicians should question patients presenting with a complaint of sexsomnia about snoring and other symptoms suggestive of sleep-disordered breathing.
5. Whereas sexsomnia is probably not nearly Buy card master xanax - as prevalent as disorders such as OSA, the immediate need to identify and treat these cases should not order xanax no prescription overlooked. Treatment is urgent seeing that there is potential of Get prescribed xanax - sexual assault on an adult or minor during sleep, which could have tragic consequences buy card master xanax both the victim and the perpetrator.
6. Most reported cases of sexsomnia have involved male patients with histories of non-REM sleep parasomnia (confusional arousals, SW, sleep terrors), with the sexual behaviors emerging after the parasomnias had been well-established, often beginning in childhood. (2-6)
7. Most forms of sexual behavior have been reported to occur with sexsomnia, including sexual vocalizations, masturbation, fondling another person, and sexual intercourse (with Buy card master xanax - or without climax). PSG studies Buy card master xanax - documented the Non-REM sleep parasomnias in many of these cases, although sexual behaviors were rarely documented during the PSG studies.
8. Also, seven published cases of sexual behaviors during sleep were documented to have resulted from sleep-related seizures (involving sexual hyperarousal, ictal orgasm and ictal sexual automatisms) in patients with epilepsy. Therefore, abnormal sexual behaviors during sleep almost always are a manifestation of either a non-REM sleep parasomnia, OSA, or sleep-related seizures. (Whether RBD with sexual behaviors exists is still open to question).
9. Buy card master xanax, In the preponderance of published cases, therapy of the sexsomnia has been effective, such as Buy card master xanax - clonazepam for non-REM parasomnias (and presumed RBD with sexual behaviors), nCPAP for OSA, and order xanax no prescription anti-convulsant medications for sleep-related sexual seizures.
10. buy card master xanax with a psychiatrist or psychologist should always be considered in buy card master xanax overall management of these cases, either to deal with a personal or interpersonal/marital issues promoting or aggravating the sexsomnia, and/or to deal with any Get prescribed xanax - adverse personal or interpersonal consequences from the sexsomnia. (3,4)
11. It should also be noted that the sleepwalking variant of sexsomnia can manifest as an elaborate form of Pseudo-Paraphilia that also could carry forensic and adverse psychosocial consequences. This is described in my book found on this website, Paradox Lost: Midnight in the Battleground of Sleep and Dreams (7).
12. Finally, a chapter entitled, Abnormal Sleepsex: Unknowing, buy card master xanax Intimacy is contained in my second book on sleep disorders, Buy card master xanax : Sleep: The Mysteries, The Problems, and The Solutions (8).
* Get prescribed xanax : Adapted from Reference #1, with permission from the publisher.
1. Schenck CH. Uncontrolled Intimacy: Sexual Sleep Disorders [Case Report]. Sleep buy card master xanax 2007; 8(7): 24-28.
2. International Classification of Sleep Disorders-Second Edition (Diagnostic & Coding Manual). Westchester, IL: American Academy of Sleep Medicine, 2005.
3. Schenck CH, Arnulf buy card master xanax Mahowald MW. Sleep and sex: what can go wrong? A review of the literature on sleep related order xanax no prescription and abnormal sexual behaviors and experiences. Sleep 2007;30:683-702.
4. Guilleminault C, Moscovitch A, Yuen Get prescribed xanax : K, Poyares D. Atypical sexual behavior during Get prescribed xanax : sleep. Psychosom Med 2002; 64:328-36.
5. Shapiro CM, Trajanovic N, Fedoroff JP. Sexsomnia—a new parasomnia? Can J Psychiatry 2003;48:311-17.
6. Rosenfeld DS, Elhajjar AJ. Sleepsex: a variant of sleepwalking. Arch Sex Behav 1998;27:269-78.
7. Schenck CH. Paradox Lost: Get prescribed xanax : Midnight in the Battleground of Sleep and Dreams. Minneapolis: Extreme-Nights, LLC 2005. (www.parasomnias-rbd.com)--this website
8. Schenck CH. Sleep: The Mysteries, The Problems, and The Solutions. New York: Avery/Penguin Press 2007. (Amazon.com)