Medically reviewed by
Dacelin St Martin, MD
Triple board-certified in Sleep Medicine,
Internal Medicine, and Pediatrics.
What is Paradoxical Insomnia? | How Common is Paradoxical Insomnia? | Causes | Symptoms | Diagnosis | Treatment
Overview
Sleep is a complicated process, and one’s perceptions of sleep duration or quality can occasionally be inaccurate.
While insomnia is a sleep disorder characterized by difficulty establishing and maintaining sleep and poor sleep quality, someone with paradoxical insomnia believes they had not had much sleep when they had a normal or close to normal sleep.[1]
It’s a state of sleep misperception. Even though paradoxical insomnia isn’t well understood by sleep experts, increasing research into its causes is beginning to shed light on the illness and its potential remedies.[2]
What is Paradoxical Insomnia?
Paradoxical insomnia is otherwise known as sleep state misperception. It’s a type of sleep dysfunction that makes people feel like they have been awake all night even when they slept, causing them to underestimate the amount of sleep they get each night.
Individuals with this disorder may feel as if they have slept for a short time despite resting for a pretty average time.
Research on paradoxical insomnia has been hampered by an absence of consensus among sleep experts on the quantitative criteria for objective and subjective sleep length.
According to a study, the prevalence of paradoxical insomnia ranged between 8 to 66 percent, depending on the characteristics used in sleep tests.[3]
This finding makes estimating the frequency of paradoxical insomnia in the general population problematic.
People who have insomnia, sometimes called objective insomnia, often have a discrepancy between how long they think they slept and how long they were actually asleep.[4] However, this difference is even more pronounced in people with paradoxical insomnia.[4]
Despite sleeping for an average amount of time and suffering limited impairment during the day, people who suffer from this disorder experience many symptoms as those with objective insomnia.[5]
Also, paradoxical insomnia appears to have a comparable effect on stress levels as objective insomnia.[5]
How Common is Paradoxical Insomnia?
People with paradoxical insomnia will typically present with insomnia or excessive sleepiness during the day.[1]
According to surveys, 15 to 20 percent of the general adult population suffers from severe insomnia.[6] Between 2 to 5 percent of the adult population complains of excessive sleepiness. Among many patients evaluated in sleep disorders clinics, 9 percent of patients complaining of insomnia and 5 percent of patients complaining of sleepiness were classified as having paradoxical insomnia.[6]
As a result, only a tiny proportion (less than 10%) of insomnia and sleepiness patients would fall into this diagnostic category. According to a multi-center field trial of diagnostic systems, 6.6 percent of cases were diagnosed with paradoxical insomnia.[6]
What Causes Paradoxical Insomnia?
Sleep scientists are not sure about the exact cause of paradoxical insomnia.
It’s believed that a lot of research is still needed to decipher the cause of this sleep disorder.[3]
However, according to a study, paradoxical insomnia may be associated with specific personality characteristics, such as neuroticism. The correlation could be explained by individuals who exhibit these characteristics, including a propensity for anxiety and elevated arousal levels, but research into this connection is ongoing.[3]
Another hypothesis postulates that paradoxical insomnia is caused by differences in the sleep neural structure that are not detectable using current investigative methods.[2]
Furthermore, studies show that people with paradoxical insomnia exhibit altered brain activity suggestive of arousal during sleep, absent in individuals who do not have insomnia and those who have objective insomnia.[4]
Symptoms of Paradoxical Insomnia
Anyone with paradoxical insomnia will typically complain that they are awake at night or only sleep for a few hours each night, even though they slept long enough to feel refreshed.[4]
Also, people with paradoxical insomnia usually don’t have significant functional impairments despite complaints of inadequate sleep.[7]
Additionally, due to the distress caused by the perceived lack of sleep, paradoxical insomnia may also result in sleep disturbances over time.[7]
Diagnosis of Paradoxical Insomnia
Your doctor will require you to take polysomnography to make a diagnosis of paradoxical insomnia.
Polysomnography will help your sleep doctor confirm your actual sleep duration, and this is then compared to your reported sleep length.[8]
Alternatively, paradoxical insomnia can be diagnosed using actigraphy.[9] It’s an investigative technique that objectively measures your sleep parameters and average motor activity over time with wearable wristwatch technology.[9]
The diagnosis of paradoxical insomnia is a rarity because anyone with this condition will typically complain of symptoms of sleep deprivation.
Many sleep experts don’t suspect paradoxical insomnia unless the patient doesn’t respond to typical treatment modalities for insomnia.
Additionally, your doctor will only say you have paradoxical insomnia if no other physical or mental condition is responsible for the misperception of your sleep.
Treatment Modalities For Paradoxical Insomnia
While there is no universally accepted therapy regimen for paradoxical insomnia, several possible treatment options exist.[6]
Your sleep doctor will typically give the best treatment options for you. Paradoxical insomnia could be treated with medications like antipsychotics and sedatives.
The adverse effects of these medications can be problematic, and there is no proof that these drugs are effective.[6]
Alternative treatment modalities include sleep education, sleep hygiene, and relaxation techniques. Sleep education is frequently given in combination with a sleep study.
Your sleep doctor will educate you on your sleep and discuss the findings from your sleep study.
Cognitive-behavioral therapy is another treatment option.[10] It employs therapeutic strategies to uncover problematic thought patterns and behaviors and replace them with more beneficial ones.
Cognitive-behavioral therapy has been shown to enhance sleep quality and perceived sleep time in persons with insomnia, making it a potentially effective treatment for paradoxical insomnia.[10]
Prognosis
The outlook for paradoxical insomnia is not clear. However, do not hesitate to see your sleep doctor if you have insomnia symptoms.
Prompt diagnosis and treatment of paradoxical insomnia can help to improve your quality of life.
References:
- American Academy of Sleep Medicine. (2014). The International Classification of Sleep Disorders – Third Edition (ICSD-3). Darien, IL. https://aasm.org/
- Rezaie, L., Fobian, A. D., McCall, W. V., & Khazaie, H. (2018). Paradoxical insomnia and subjective-objective sleep discrepancy: A review. Sleep Medicine Reviews, 40, 196–202. https://pubmed.ncbi.nlm.nih.gov/29402512/
- Castelnovo, A., Ferri, R., Punjabi, N. M., Castronovo, V., Garbazza, C., Zucconi, M., Ferini-Strambi, L., & Manconi, M. (2019). The paradox of paradoxical insomnia: A theoretical review towards a unifying evidence-based definition. Sleep Medicine Reviews, 44, 70–82. https://pubmed.ncbi.nlm.nih.gov/30731262/
- Martucci, M., Conte, M., Ostan, R., Chiariello, A., Miele, F., Franceschi, C., Salvioli, S., Santoro, A., & Provini, F. (2020). Both objective and paradoxical insomnia elicit a stress response involving mitokine production. Aging, 12(11), 10497–10505. https://pubmed.ncbi.nlm.nih.gov/32420904/
- Geyer, J. D., Lichstein, K. L., Ruiter, M. E., Ward, L. C., Carney, P. R., & Dillard, S. C. (2011). Sleep education for paradoxical insomnia. Behavioral Sleep Medicine, 9(4), 266–272. https://pubmed.ncbi.nlm.nih.gov/22003980/
- “Paradoxical Insomnia.” MedLink Neurology, https://www.medlink.com/articles/paradoxical-insomnia.
- Sánchez-Ortuño, M. M., Edinger, J. D., & Wyatt, J. K. (2011). Daytime symptom patterns in insomnia sufferers: Is there evidence for subtyping insomnia? Journal of Sleep Research, 20(3), 425–433. https://pubmed.ncbi.nlm.nih.gov/21205038/
- A.D.A.M. Medical Encyclopedia. (2020, January 19). Polysomnography. Retrieved September 28, 2020, from https://medlineplus.gov/ency/article/003932.htm
- Martin, J. L., & Hakim, A. D. (2011). Wrist actigraphy. Chest, 139(6), 1514–1527. https://pubmed.ncbi.nlm.nih.gov/21652563/
- Wenzel, A. (2017). Basic strategies of cognitive-behavioral therapy. Psychiatric Clinics of North America, 40(4), 597–609. https://pubmed.ncbi.nlm.nih.gov/29080588/
