The inclusion of a new sleep disorder in the DSM-5 might raise awareness of the underreported diagnosis and help physicians better identify the condition.
Sexsomnia can present in different forms but is generally described as engaging in sexual activity while asleep.
“Classification of sexsomnia in DSM-5 adds legitimacy to the diagnosis as it takes it out of the proposed diagnosis or research diagnosis realm and places it into a formally accepted classification manual,” said Dr. Brandon G. Moore, a psychiatry resident at Western Michigan University in Kalamazoo. “The classification of the diagnosis helps patients in that it opens up the topic for further discussion and education of providers so that they may more readily recognize the disorder and offer appropriate treatment.”
Sexsomnia can involve varying degrees of sexual activity while unconscious, including masturbation, fondling, groping, and intercourse. Patients often are unaware they have the condition, and signs of the disorder frequently are reported by a partner, roommate, or spouse, Dr. Moore said in an interview. The condition is not well known to many doctors, which can lead to misdiagnoses and underdiagnoses, added Dr. Kannan Ramar, an internist who practices in the division of pulmonary and critical care medicine, and the Center for Sleep Medicine at the Mayo Clinic, Rochester, Minn.
“Awareness of this condition is not there among the medical community,” Dr. Ramar said in an interview. “More educational awareness needs to happen, and having this diagnosis listed in the DSM-5 is one right step in that direction.”
Dr. Moore recently treated a 44-year-old patient with sexsomnia referred by his neurologist. The patient originally presented for presumed restless legs syndrome but had a history of sleep-related sexual behavior. The neurologist instructed the patient and his wife to keep a sleep diary, which revealed sexual behavior by the patient during sleep, including intercourse, that had been occurring for the last 20 years, according to a case study poster by Dr. Moore presented at the American Academy of Psychiatry and the Law meeting.
Polysomnography indicated no significant sleep-disordered breathing or limb movements but did reveal episodes during non-REM sleep consistent with confusional arousal. After a diagnosis of parasomnia associated with sexual behavior, the patient was referred for psychiatric evaluation because his behavior, exacerbated by stress, was becoming increasingly aggressive and adversely affecting his marriage. The patient has since improved with the addition of paroxetine, an increase of his clonazepam dosage, as well as with psychotherapy, Dr. Moore reported.
Collecting collateral information about sleep habits from partners or roommates can help doctors pinpoint the possibility of sexsomnia, Dr. Moore said.
“Any sleepwalking disorder or history should at least raise some suspicion, but a bed partner who reports (any) physical or sexual contact that is unwanted should be explored,” he said.
Family physicians, internists, and other specialists also play a primary role in identifying sexsomnia in patients and conferring with sleep specialists.
“Knowing when to refer and/or when to call to get more information or help is needed to help manage patients with sleep disorders,” Dr. Ramar said. “Family physicians play a key role, as they are usually the first physician that a patient might see with a sleep disorder. If the treatment plan that is established for the patient does not work, then a referral to a sleep specialist is needed.”
Sexsomnia might be included as a diagnostic specifier when criteria for non-REM sleep arousal disorder, sleepwalking type, are met and accompanied by evidence of sleep-related sexual behavior.
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