Sleep Soundly Every Night, Feel Fantastic Every Day (28 page)

In a 2005 Canadian case, the court acquitted a man of sexually assaulting a woman who awakened him after both fell asleep at the house where they attended a party. The accused admitted he had been drinking. All he could say about the sexual assault was that he had no memory of it. No memory implied there was no intent to commit the act. His defense also proved he had a medical condition, a sleep
disorder, in which sexual behaviors were performed and, of course, witnessed by the accuser.

In similar prosecuted cases in the United States and in Britain, some of the accused were acquitted while other defendants were found guilty. The forensic evidence is summarized in the following paragraph, which explains the unconscious action, the amnesia that happens in sexsomnia. The term
somnambulism
refers to sleepwalking, and the term
automatism
refers to the unconscious nature or automatic, uncontrolled behavior of sleep sex.

     
Somnambulism or sleepwalking is a viable defence on the basis of automatism. The behaviours that occur during sleepwalking can be highly complex and include sexual behaviour of all types. Somnambulistic sexual behaviour (also called sexsomnia, sleep sex) is considered a variant of sleepwalking disorder as the overwhelming majority of people with sexsomnia have a history of parasomnia and a family history of sleepwalking.

As I see it, the defense should consider the presence of obvious sleep disorders such as sleep apnea or another sleep disturbance to explain the cause of arousal from deep, deltawave sleep, also known as slow-wave sleep. They should also consider sleepwalking, night terrors, epilepsy, or a REM sleep behavior disorder. Each of these could cause nocturnal sexual behaviors. The testimony by one or several additional witnesses, such as previous bed partners or family members, could verify previous sex sleep behavior. This is very important to show that sexual behavior while asleep is prominent in the history of the defendant, since sexsomnia is repetitive. The intention to commit the crime would be nonexistent in persons who have sexsomnia, because they have no memory of the event. Horrified and mortified that they could commit the act, they make no attempt to hide or lie about it. Such defendants are not normally evasive.

Q.
 
What medicines are used for sexsomnia?

A.
 
The most commonly used medication is called clonazepam. This drug is also used in refractory sleepwalking. However, eliminating alcohol and looking for an underlying primary sleep disorder that might be triggering the episodes is paramount.

Q.
 
My live-in girlfriend complained of me trying to have sex with her in my sleep for the third time. I wake up with no recollection of doing anything and am worried for her safety. I had a couple episodes of sleepwalking when I was young, but no other history of actions during my sleep. I have noticed that each time I've had a “sexsomniac slip” she and I had gone to bed upset with each other. Could stress be causing me to do this? Is there any way to lessen my chances of doing things I don't want to without medication?

A.
 
Yes, stress as well as sleep deprivation, medications, and primary sleep disorders such as sleep apnea, can be the cause. I think it is important that you consult with a sleep specialist in your area. A thorough sleep workup would seem to be indicated.

 

 

The bed is a bundle of paradoxes: we go to it with reluctance, yet we quit it with regret; we make up our minds every night to leave it early, but we make up our bodies every morning to keep it late.

—OGDEN NASH

Eating and sleeping are two of our most basic biological needs, both controlled by the natural circadian rhythm of our bodies. Normal processes include a delicate balance of chemistry—most notably between glucose, insulin, and the hormone leptin—that regulates appetite and metabolism while we sleep. When this rhythm is out of balance, disorders affecting our sleep and eating habits can result. A. J. Stunkard, a medical doctor who identified night eating syndrome and eventually founded the Center for Weight and Eating Disorders at the University of Pennsylvania's Perelman School of Medicine, found the underlying cause to be a misfiring of the circadian rhythm that resulted in delayed meal timing.

Sleep-related eating disorders are relatively rare, affecting only 1% to 5% of the population; however, they are severely disruptive to the person's physical and mental well-being, causing obesity and sometimes, other risky behaviors. They are also indicative of other underlying problems such as genetic predispositions, hormonal and neurochemical disturbances, and mood disorders. Individuals with an eating disorder also often have sleep disorders.

 

In night eating disorders, the circadian eating cycle is out of phase with the circadian sleep–wake cycle. The sleep–wake cycle remains relatively normal, but the timing of eating is out of sync, resulting in over 30% of caloric intake to occur after dinner. There are two forms of night eating, and both disorders are characterized by the high intake of simple sugars and fats, causing weight gain. Both also occur during non–rapid eye movement (non-REM) sleep.

Sleep-related eating disorder
is associated with disrupted sleep, weight gain, and major chronic morbidity. It is a type of sleepwalking with onset associated with several medications such as Ambien (zolpidem), as well as with other sleep disorders such as obstructive sleep apnea, periodic limb movement, and restless legs syndrome (RLS).

In this disorder, the night eater usually has total amnesia of the trips to the kitchen and eating. In fact, many of these people wake up with food in their bed or stove burners left on and no recollection of what happened.

Night eating syndrome,
the second form, refers to the eater being conscious while engaged in uncontrollable eating after bedtime. It is not unusual for these people to consume over 50% of their daily caloric intake after bedtime.

A sleep-related eating disorder refers to the patient who gets out of bed while asleep and eats. Sometimes the sleeper eats bizarre food or combinations of foods. The biggest dangers are:

1.
 
Environmental, as in leaving a gas flame or an electric burner on, burning foods if cooking, using knives, or breaking glassware—the options are as numerous as the dangerous objects in your kitchen.

2.
 
Personal, as in the case of a sleeper ingesting poison, drinking dish detergent, cutting him- or herself with a knife, and such.

Over the years, I have treated several patients with SRED. In terms of parasomnias, SRED is closely related to sleepwalking, and the sleeper may begin with sleepwalking and then move on to sleep eating. When this happens, eating usually becomes the primary sleep disorder activity.

Those suffering from SRED are usually fully asleep when they get out of bed, go to the kitchen, and begin eating (although some have reported being “half-awake, half-asleep”). Research shows that for most patients, this occurs during slow-wave sleep, which is a deep, non-REM phase. They put on weight, are not hungry for breakfast in the morning, and report nonrestorative sleep and daytime fatigue. They eat large quantities of food that are high in carbohydrates, and these eating sessions are similar to bulimic binges. However, unlike bulimics, those with SRED do not purge. The more disturbing aspect of this condition is the possibility of eating the inedible or harmful substances, such as caustic acids. These episodes can occur on a nightly basis, and rarely more than once a night.

Often another person in the house is the first one to observe the clues to the disorder: food in the bed, a stove burner left on, a mess in the kitchen, or finding the sleeper engaged in the eating behavior. These episodes have been described as “involuntary” and “out of control,” which can later be confirmed by monitoring the person in a sleep clinic. The sleep technician would report that the sleeper showed bodily movements like chewing or eating when food was left next to the bed. Of course, the person's lack of awareness presents an entirely different set of dangers such as self-injury.

SRED was first identified in 1991, and has recently received media attention because of an association with the sleep aid Ambien. Also known as zolpidem, this drug is widely acknowledged as a cause of SRED in some cases and is part of a larger problem that includes sleepwalking and sleep driving. For most people, SRED has an underlying sleep-related cause, such as obstructive sleep apnea, RLS, or periodic limb movement disorder. According to one survey, 50% of patients with SRED had RLS. SRED has also been linked with daytime anxiety and other psychological issues. In the case of SRED, discontinuing the offending medication or treating the primary sleep disorder can be curative.

We eventually determined an underlying sleep-related cause at the root of Janice's trouble. Janice, a 23-year-old woman, had been experiencing daytime fatigue for the past several months, even though her sleep habits had not changed. Despite going to bed at a reasonable hour each night and sleeping for eight hours, she never felt refreshed. She had not changed her eating habits either, but had gained several pounds, which distressed her. Janice came to the clinic after her partner, Jon, found her in the kitchen at 1:30 a.m. Jon observed that Janice had opened the refrigerator and had placed assorted foods like mustard, one bag of deli meat, a jar of dill pickles, and frozen ice cream bars on
the kitchen counter, and she was eating a dill pickle with mustard. She also seemed to be asleep and didn't respond when Jon called her name, asking if anything was wrong.

The next day, Janice had no recollection of what had happened. Since then, Jon observed the same behavior three more times and became alarmed when he saw her pouring cleaning fluid into a drinking glass. He led her back to bed before she could drink it.

I could see Janice was relieved to be getting help for her “bizarre” story, as she described it. Upon waking in the morning, she had no recollection of eating anything or even getting out of bed. I advised Janice and her partner Jon to remove all knives and other sharp objects, as well as any dangerous chemicals, from the kitchen before bedtime. She told me she had a history of occasional sleepwalking over the years. She also related that her mother had been known to sleepwalk.

After taking her history, I arranged a sleep study for Janice. She would spend a night in the sleep clinic, as this appeared to be a classic case of sleep eating. The reason for doing a sleep study was that we were looking for an underlying sleep disorder that might be triggering these undesirable behaviors.

In couples like Janice and John, I have to be very matter of fact. As time goes on, they may become lax in keeping to the specific instructions I give them. Removing the toxic or dangerous materials from the kitchen is not a choice. It must be done. Jon needs an alarm sensor or bed pad sensor so he wakes up when Janice gets out of bed and can gently guide her back to bed to prevent her from harming or even killing herself.

The results of Janice's sleep study through polysomnography revealed that Janice exhibited numerous arousals from sleep during the night, all while in a deep or slow-wave sleep phase. This was important because most SRED occurs out
of this stage of sleep. We determined that Janice had sleep apnea that was causing these arousals. We started her on continuous positive airway pressure (CPAP) titration to treat the sleep apnea and within a few weeks Janice's symptoms began to improve; her bingeing sessions became less frequent over time, and she felt more rested during the day. She also began losing weight. It's been over a year and Janice has had no more episodes of SRED.

First, it is essential to resolve any underlying sleep problems that could be triggering the SRED. Pharmacological treatments for SRED include clonazepam, a benzodiazepine commonly used for uncontrolled sleepwalkers; pramipexole, an agent that stimulates dopamine receptors in the nervous system and is used frequently for RLS; and topiramate, an antiseizure medication that has been found to have appetite-suppressing ability. While many patients have reported success with these treatments, there are no guarantees. I still advise patients to make their living environment as safe as possible.

Twenty-five-year-old Susan had been suffering from anorexia since she was a teenager. Over several years of psychotherapy treatment, she was able to maintain a healthy weight. However, her diet was still regimented and controlled. She also suffered from occasional bouts of depression. In recent months, Susan woke often in the middle of the night with a strong desire to eat. She did not recall feeling particularly hungry, just a feeling that she would not be able to get back to sleep unless she ate. After trying unsuccessfully to resist, she would eventually go to the kitchen, where she consumed large quantities of food, and eventually gained weight with the intake. She consumed most of
her calories after dinner, and arose from bed repeatedly to go to the kitchen.