What Is Sleep State Misperception (Paradoxical Insomnia?)

If you're struggling with insomnia, but nobody believes you because you're showing no signs of sleep deprivation, you could have paradoxical insomnia. 

Also called sleep state misperception, paradoxical insomnia is a condition where you sincerely believe that you haven't been sleeping long enough or well enough, even though all physical signs and diagnostic testing show that you're sleeping normally. 

In other words, paradoxical insomnia causes individuals to severely underestimate or overestimate the amount of sleep they are getting. This condition affects up to 50%¹ of people with insomnia. 

Paradoxical insomnia makes you think you were awake

Paradoxical insomnia is the modern term for a condition described by the third edition of the International Classification of Sleep Disorders (ICSD) as:

"... a complaint of severe sleep disturbance without corroborative objective evidence of the degree of sleep disturbance claimed."

The lack of corroborative evidence means that you don't exhibit the symptoms of somebody with insomnia, such as difficulty falling asleep, daytime tiredness and sleepiness, difficulty focusing on tasks, poor work performance, and sudden lapses into sleep, nor the signs that would be elucidated using diagnostic testing such as a polysomnography.

This condition, also known as sleep state misperception, has a vague medical definition because experts still don't know much about it despite being aware of it for decades.

Paradoxical insomnia is a sleep disorder sometimes referred to as subjective insomnia. It causes very real distress and torment in those suffering from the condition because they genuinely feel and believe that they aren't sleeping well.

Signs that you may have paradoxical insomnia

The first sign that you have paradoxical insomnia is a feeling of severe sleep disturbance or insomnia, despite relatively mild daytime impairment (excessive sleepiness, unintended lapses into sleep). 

People suffering from paradoxical insomnia report extended periods of little or no sleep but little or no effect on their daily function.

In one study,² a person with paradoxical insomnia reported that she hadn’t slept properly for ten years. When polysomnography was conducted, it indicated that she had slept for eight hours despite complaining of having slept for “only one hour.”

This discrepancy is a classic symptom of paradoxical insomnia. When sleeping, people with paradoxical insomnia also experience heightened awareness of their surroundings. They respond more strongly to stimuli such as sounds and lights and experience high mental activity such as racing thoughts.

Despite having normal sleep latency (the time it takes you to fall asleep), people with this condition feel it takes them forever to fall asleep. This is thought to be an effect of heightened brain stimulation.

Although research is limited, the latest data suggest that brief awakenings and other non-specific abnormalities shown on EEG during sleep contribute to the tendency to misperceive sleep in those who have paradoxical insomnia.

Potential causes of sleep state misperception

Medical researchers are yet to uncover the cause of sleep state misperception. However, current evidence suggests three most likely mechanisms to explain the misperception.

Sleep being misperceived as wake, worry, and selective attention toward sleep-related concerns and the presence of brief awakenings. 

Due to these and other factors, your perception of time will also be warped. You might believe that you only slept for two hours while you actually slept for six or seven hours.

Paradoxical insomnia often occurs alongside other disorders, including:

• Depression

• Post-traumatic stress disorder (PTSD); 70%³ of people who have PTSD also have some form of insomnia.

• Obstructive sleep apnea (OSA) — a sleep-breathing disorder that makes individuals more likely to underestimate or overestimate the total time they slept; however, the causal link is not established.

• Paradoxical sleep disorder is also related to some personality traits, such as neuroticism.

How paradoxical insomnia is diagnosed

If your doctor suspects you have paradoxical insomnia, they will likely refer you to a sleep specialist. The specialist will perform a sleep study, also called a polysomnography. The study involves many tests ("poly"), including breathing, heart rate, blood oxygen levels, and body movements such as eye movements.

During the test, the sleep specialist will also take an electroencephalograph (EEG), a test in which electrodes are attached to the scalp to measure brain activity. All these measurements will show exactly when you fall asleep, how well you sleep, and the quality of your sleep.

To be medically diagnosed with sleep state misperception or paradoxical insomnia, you must:

• Sleep for 6.5 hours or longer, on average

• Have a sleep efficiency rating of 85 or higher

• Show less impaired daytime functionality than an insomniac would 

• Feel that you have had consistent insomnia for at least six months⁴

This mismatch between your perceived lack of sleep and the medical results will help a sleep expert diagnose you with paradoxical sleep. Although comparing subjective and objective findings is mainly utilized to diagnose paradoxical insomnia, the clinical interview alone can help establish the diagnosis if the clinical complaint is extreme.

Effects of sleep state misperception: does it affect relationships?

Even though you're actually sleeping better than you think, suffering from sleep state misperception could seriously affect your quality of life. The biggest problem is emotional distress and anger, anxiety, and tension.

When those close to you, such as your partner, family members, friends, and colleagues, don't believe that you actually have insomnia and are simply looking for attention, it could heighten the level of emotional distress. Eventually, they might not even want to talk to you about it.

You could worsen things if you attempt to self-treat with medication such as Sominex, Nytol, and Unisom. These OTC sleep tablets will make you drowsy, but they will become less effective over time. They can also lead to dizziness, dry mouth, and daytime drowsiness.

Treatment for paradoxical insomnia: sleep education

Since sleep state misperception is a problem of sleep perception, behavioral interventions are used to manage and treat the condition. A type of cognitive behavioral therapy is designed to help you change how you think about or perceive sleep.

One of the most effective options is the paradoxical intention,⁵ a form of cognitive therapy in which you learn to confront your fear of remaining awake and its negative effects. For example, you might face the consequences of poor sleep on daytime functioning.

What this does is help relieve the anxiety and tension around sleeping immediately at night. That's the paradox: you actually stay awake in order to fall asleep faster and sleep more deeply.

With sufficient training, you learn to stop "trying" to sleep, which works against falling asleep. Once quiet, calm wakefulness becomes an option for you, you find that you fall asleep in those conditions, i.e., with good sleep hygiene.

• Stay asleep until you feel sleepy.

• When it's time to retire to bed, turn off all the lights and sounds and get in bed.

• Rest in bed without any attempt to sleep. Instead, try and maintain passive wakefulness and calmness, and rest with your eyes closed.

• You can also attempt breathing exercises, progressive muscle relaxation, and guided imagery to help you stop trying to sleep.

• With training, the anxiety of trying to sleep will diminish as wakefulness becomes a viable alternative, and eventually, you will fall asleep faster and sleep normally.

This behavioral treatment is also called sleep education. It has no risks or side effects and has been proven to be very effective. Talk to a sleep specialist if you can't carry it through on your own. 

Anyone trained in sleep medicine can help you with this type of therapy, including your physician, psychiatrist, or psychologist.

The lowdown

Sleep state misperception, also called paradoxical insomnia, is a condition in which you feel as if you have insomnia even though all evidence shows otherwise. 

Paradoxical insomnia can be managed and treated with behavioral therapy and sleep education. By training yourself to stay awake, you let go of the tension of trying to fall asleep and will actually fall asleep faster and more deeply.

Treatment protocols involving traditional antipsychotic drugs and benzodiazepines⁶ may be used in extreme cases. Talk to your doctor or request a referral to a sleep expert for professional assistance.