Insomnia (sleeplessness) is characterized by a difficulty to initiate or maintain sleep not due to time constraints, resulting in daytime impairment, which may include sleepiness, fatigue, as well as cognitive problems (e.g., impaired memory and concentration). If you have been suffering from insomnia for at least 3 months, you would be diagnosed with Chronic Insomnia Disorder, which is a persistent form of insomnia. Now, if you believe that you “never sleep well,” we could further narrow your diagnosis to a primary insomnia known as Paradoxical Insomnia (formerly known as sleep-state misperception). It is primary because it is not caused by a secondary medical condition.

Do you suffer from paradoxical insomnia?

If you’re suffering from paradoxical insomnia, you may feel as if you never sleep.

However, if you ever went through a sleep study or used sleep tracking technology, you may have been amazed to find out you actually do sleep. That’s why this condition was previously known as sleep-state misperception. Sufferers of paradoxical insomnia do not feel as if they are getting enough sleep, though they actually do.

Even if you never tracked your sleep with objective measures, you may still have noticed that the daytime impairment you experience is much less severe than expected from the extreme sleep deprivation you perceive your self of suffering from.

What is paradoxical insomnia?

Sleep scientists have limited understanding of this condition. One theory which attempts to explain it is known as the Two-Factor Model, proposed by Bonnet and Arand in 1997. The two factors are:

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  • Basal Arousal Level – What is your normal level of arousal relative to others? (The level of arousal reflects your level of wakefulness and alertness.) Is your basal arousal level lower of higher than that of others?
  • Sleep Requirement – How much sleep do you require relative to others? Do you require a shorter or longer sleep than most other people?

Arising from different combinations of these factors are 4 distinct conditions:

  1. People who have a low basal arousal level and a short sleep requirement may suffer from excessive daytime sleepiness.
  2. People who have a low basal arousal level and a long sleep requirement may suffer from idiopathic hypersomnolence, characterized by excessive daytime sleepiness even after 7 hours or more of quality sleep.
  3. People who have a high basal arousal level and a short sleep requirement may suffer from psychophysiological insomnia or idiopathic insomnia.
  4. People who have a high basal arousal level and a long sleep requirement may suffer from paradoxical insomnia, characterized by complaints regarding sleep that are not supported by objective measures which show adequate sleep, and without the level of daytime impairment expected.

Long story short, according to the Two-Factor Theory, paradoxical insomnia characterizes people who require a relatively long sleep duration, while having a high basal arousal level.

Since they are very aroused normally, they find it difficult to fall asleep. During the long hours they spend in bed, due to their high arousal levels, they may be awake or sleep lightly a significant proportion of the night, making them think they barely sleep.

But when they go through a sleep study, PSG and actigraphy show that their subjective sleep estimates are wrong and that their sleep is normal.

Indeed, the easiest way to recognize people who suffer from paradoxical insomnia is to check if there’s a mismatch between insight into total sleep time and real total sleep time as measured with objective measures.

How do paradoxical insomniacs sleep, according to objective measures?

Their sleep is less stable during light sleep, and sometimes a period of light sleep between two awakenings can seem like a long period of awakening.

Why does paradoxical insomnia happen?

Currently, science has no answer to these question, however it is associated with depression, anxiety, and hypnotic drugs.

In those who don’t suffer from depression, anxiety, and never used sleeping pills, the condition may reflect physiological traits such as shallow sleep, a high arousal level, a long sleep requirement, etc..

Treatment of paradoxical insomnia

I will start by stating what is not a useful treatment approach: Benzodiazepines and other sleeping pills should not be administered long-term for the treatment of paradoxical insomnia.

In fact sleeping pills may repress deep sleep, thereby increasing time spent in shallow sleep and inducing paradoxical insomnia.

If depression or anxiety are present, they should be addressed with psychotherapy.

Sleep efficiency, sleep intensity (depth), sleep continuity, and sleep hygiene should be improved through lifestyle modification.

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Other than that, paradoxical insomnia is treated like other primary insomnia disorders: with a combination of cognitive-behavioral strategies, including stimulus-control therapy, sleep-restriction therapy, and relaxation.

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References

Kryger, Meir H.; Roth, Thomas; Dement, William C.. Principles and Practice of Sleep Medicine E-Book. Elsevier Health Sciences. Kindle Edition.

Westerman, David, E., The Concise Sleep Medicine Handbook: Essential Knowledge for the Boards & Beyond. (5th ed.) GSSD Publishers, LLC.

Summary
Paradoxical Insomnia (Sleep-State Misperception)
Article Name
Paradoxical Insomnia (Sleep-State Misperception)
Description
Paradoxical insomnia (sleep-state misperception) is a chronic form of insomnia where subjective sleeplessness is experienced with no objective sleep disruption. This article covers what we currently know about this condition, including causes, symptoms, and treatment approaches.
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