What is the Psychology of Sexsomnia?

Sexsomnia is a complex and often distressing sleep disorder where individuals engage in sexual activity while in a sleep state, highlighting the intricate relationship between our conscious and unconscious processes during rest.

Understanding Sexsomnia as a Parasomnia

From a psychological perspective, sexsomnia is primarily understood as a parasomnia. Parasomnias are abnormal behaviors, experiences, or physiological events that occur during sleep, specific sleep stages, or sleep-wake transitions.

As officially recognized, Sexsomnia is recognised in the DSM-5 diagnostic manual of psychiatric conditions and is a type of parasomnia, a disorder involving abnormal sleep behaviour. This classification underscores its nature as a neurological sleep disorder rather than a volitional act or a psychological impulse from waking life.

The key psychological characteristics of sexsomnia, as highlighted in its definition, include:

• Non-REM Sleep Occurrence: Sufferers engage in sex acts while in non-REM sleep. This is crucial because non-REM sleep (stages N1, N2, N3) is typically a period of deep, restorative sleep, not associated with dreaming or conscious awareness. The occurrence during non-REM sleep distinguishes it from behaviors related to vivid dreams during REM sleep.
• Profound Lack of Awareness: Individuals experiencing sexsomnia have no awareness of their behavior during an episode. They are not consciously present or in control of their actions, even if their eyes may appear open.
• Complete Amnesia: Upon waking, sufferers will have no memory of their behavior. This post-episode amnesia is a hallmark feature of non-REM parasomnias like sleepwalking and sets sexsomnia apart from conscious sexual activity or even intoxicated behavior.

These characteristics collectively define sexsomnia as an automatic, unconscious behavior that arises from a state of incomplete arousal from deep sleep, where motor areas of the brain are active while conscious awareness remains suppressed.

Psychological and Physiological Underpinnings

While the precise psychological mechanisms are still being explored, sexsomnia is generally believed to result from a physiological instability in the brain's sleep-wake cycles. This leads to a partial awakening from non-REM sleep where certain complex behaviors can be performed without full consciousness.

Potential psychological and physiological factors that may predispose or trigger sexsomnia episodes include:

• Sleep Deprivation: Insufficient sleep is a common trigger for many parasomnias, as it can make the brain more prone to unstable sleep states.
• Stress and Anxiety: High levels of psychological stress can disrupt normal sleep architecture, increasing the likelihood of partial arousals and parasomnia episodes.
• Alcohol and Sedatives: Substances that alter brain activity or suppress REM sleep can sometimes lead to disinhibition and fragmented sleep, potentially triggering sexsomnia.
• Concurrent Sleep Disorders: Conditions such as obstructive sleep apnea, restless legs syndrome, or periodic limb movement disorder can cause fragmented sleep, making individuals more susceptible to parasomnias.
• Fatigue and Fever: Intense physical fatigue or systemic illness like fever can also destabilize sleep states.
• Genetic Predisposition: There is evidence of a familial link for parasomnias, suggesting a genetic component may increase vulnerability.
• Brain Activity: Research suggests an incomplete "switching off" of certain brain regions (like those involved in movement) and an incomplete "switching on" of others (like those involved in conscious awareness and memory) during an episode.

Psychological Impact and Considerations

The psychological consequences of sexsomnia can be profound, not only for the individual but also for their partners and relationships:

• Emotional Distress: Sufferers often experience significant shame, guilt, embarrassment, and confusion once they are informed of their actions, particularly given their complete lack of memory.
• Relationship Strain: The condition can lead to severe misunderstanding, fear, and distress for partners, potentially damaging trust and leading to accusations or emotional turmoil.
• Anxiety about Sleep: Individuals may develop sleep-related anxiety, fearing future episodes or their potential consequences, leading to avoidance of sleep or sleep-related activities.
• Safety Concerns: In some cases, there can be concerns about the safety of the individual or others during an episode, especially if the behavior is aggressive or involves non-consenting parties.
• Legal Implications: Sexsomnia has, in rare and complex legal cases, been used as a defense, highlighting the severe socio-legal ramifications of behavior performed in an unconscious state.

Diagnosis and Management Approaches

Addressing the psychology of sexsomnia involves a comprehensive approach to diagnosis and management, aimed at reducing episodes and mitigating their psychological impact.

1. Diagnosis:

• Clinical Interview: A detailed medical and sleep history, often involving a partner's account, is crucial.
• Polysomnography (Sleep Study): An overnight sleep study is typically essential. This monitors brain activity (EEG), eye movements, muscle activity, heart rate, breathing, and blood oxygen levels, helping to confirm sexsomnia and rule out other sleep disorders.

2. Management Strategies:

• Lifestyle Modifications:
  • Prioritize Sleep: Ensuring consistent, adequate sleep is foundational.
  • Avoid Triggers: Limiting or avoiding alcohol, sedatives, and recreational drugs, especially before bedtime.
  • Stress Management: Implementing stress-reduction techniques like mindfulness, meditation, or therapy.
  • Good Sleep Hygiene: Maintaining a regular sleep schedule, creating a comfortable sleep environment, and avoiding stimulating activities before bed.
• Psychological Support:
  • Psychoeducation: Educating both the individual and their partner about sexsomnia's nature as an unconscious disorder can significantly reduce guilt, blame, and misunderstanding.
  • Counseling/Therapy: Individual or couples counseling can help process the emotional distress, guilt, and relationship challenges arising from the condition. Cognitive Behavioral Therapy for Insomnia (CBT-I) may also be beneficial if sleep anxiety is present.
• Pharmacological Interventions: In some persistent or severe cases, medication (e.g., benzodiazepines like clonazepam) may be prescribed to suppress deep non-REM sleep and reduce episode frequency, often as a temporary measure.

Key Aspects of Sexsomnia

Here's a summary of the psychological and clinical aspects of sexsomnia:

Understanding sexsomnia's psychological basis as a disorder of sleep arousal, distinct from conscious behavior, is crucial for effective management and empathetic support for those affected.