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DSM-5 criteria for NREM sleep arousal disorders and sexsomnia subtype of sleepwalking Criterion A. Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by sleepwalking. Criterion B. No or little dream imagery is recalled. Criterion C. Amnesia for the episodes is present. Criterion D. Clinically significant distress or impairment. Criterion E. Disturbance is not attributable to the effects of a substance. Criterion F. Coexisting mental or medical conditions do not explain the episodes. Diagnosed as “NREM sleep arousal disorders, sleepwalking type, with sleep-related sexual behavior (sexsomnia)” ICSD-3 criteria for disorders of arousal, including sleepwalking and confusional arousal subtypes Criterion A. Recurrent episodes of incomplete awakening from sleep. Criterion B. Inappropriate or absent responsiveness to efforts of others to intervene or redirect the person during the episode. Criterion C. Limited or no associated cognition or dream imagery. Criterion D. Partial or complete amnesia for the episode. Criterion E. Another sleep disorder, mental disorder, medical condition, medication, or substance use does not better explain the disturbance. Confusional arousals: Criterion A. General NREM disorders of arousal criteria (above) are met. Criterion B. The episodes are characterized by mental confusion or confused behavior that occurs while the patient is in bed. Criterion C. There is an absence of terror or ambulation outside of the bed. Sleepwalking: Criterion A. General NREM disorders of arousal criteria (above) are met. Criterion B. The arousals are associated with ambulation and other complex behaviors out of bed. ↵* Adapted from References 1 and 2.
NREM = non-rapid eye movement
Element Explanation Efforts to conceal behavior Efforts to conceal sexual acts allegedly committed while asleep demonstrates a knowledge of the acts. Repeated episodes of sexual abuse perpetrated after being aware of the behavior An individual genuinely concerned about the effect of his sleep-related sexual behavior would be more likely to try to reduce the risk of recurrence. Recollection of the episode Sexsomnia occurs during slow-wave sleep, a time when an individual is typically not conscious. Research demonstrates that full or patchy recall of alleged events occurs in a minority of cases. New-onset sexsomnia presenting as sole parasomnic behavior One tenth to one third of patients presenting with sexsomnia in research studies have no history of current or prior nonsexual parasomnic behavior. New-onset sexsomnia with no history of other parasomnic behaviors in an individual charged with a sex offense may raise an evaluator’s suspicion. Avoidance of triggers Abstinence from alcohol and other drugs Avoid shift work that disrupts sleep schedule Stress reduction measures or psychotherapy Risk-reduction strategies Treatment with clonazepam Treatment of co-occurring sleep disorders Sleeping in bed with no bed partner Sleeping with door locked to prevent sleepwalking Forensic considerations Presence of paraphilic interests or disorders Use of automatism/unconsciousness or not guilty by reason of insanity defenses Unclear benefit from psychiatric hospitalization Unclear utility of sexual offender registry
