Paradoxical insomnia

Deirdre A Conroy PhD (Dr. Conroy of the University of Michigan has no relevant financial relationships to disclose.)
Antonio Culebras MD, editor. (

Dr. Culebras of SUNY Upstate Medical University at Syracuse received an honorarium from Jazz Pharmaceuticals for a speaking engagement.

Originally released September 6, 1995; last updated January 10, 2019; expires January 10, 2022

This article includes discussion of paradoxical insomnia, pseudo-insomnia, sleep hypochondriasis, sleep state misperception, subjective insomnia, and subjective sleepiness. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.


Paradoxical insomnia (previously called sleep state misperception) is characterized by complaints of little or no sleep over long periods of time without the level of impairment expected with such a level of sleep deprivation. Patients often describe heightened awareness of their surroundings when lying down to sleep. Sleep study reveals normal sleep architecture with normal sleep onset latency and sleep efficiency, but with subjective patient reports indicating prolonged sleep onset latency and poor sleep efficiency. Treatment usually involves patient reassurance. Behavioral therapy and sedative-hypnotics have also been tried.

Key points


• Paradoxical insomnia should be considered in patients with insomnia who complain of severe insomnia, with little or no sleep but without objective evidence of consequences commensurate with the described level of sleep deprivation.


• Patients show evidence of overestimation of sleep onset latency and underestimation of sleep efficiency.


• Patients do not show other evidence of malingering or psychopathology.


Polysomnographic recordings do not show evidence of sleep disorder, and sleep parameters such as sleep efficiency and sleep onset latency are within normal limits.

Historical note and terminology

Sleep state misperception (paradoxical insomnia) is a diagnostic term adopted in the International Classification of Sleep Disorders (American Sleep Disorders Association 1990) to replace 2 previously used diagnostic categories of sleep disorders: subjective insomnia complaint without objective findings and subjective sleepiness complaint without objective findings. In the ICSD-3 edition, the term sleep state misperception was replaced with “paradoxical insomnia” and will be used where appropriate herein (American Academy of Sleep Medicine 2014). The American Academy of Sleep Medicine developed Research and Diagnostic Criteria (RDC) for insomnia (American Academy of Sleep Medicine 2005). The RDC criteria also provide 3 subclassifications of primary insomnia: psychophysiologic insomnia, paradoxical insomnia, and idiopathic insomnia (Edinger et al 2004). Other terms used in the past to describe patients with this disorder include subjective insomnia, pseudo-insomnia, subjective sleepiness, and sleep hypochondriasis. Paradoxical insomnia implies a significant and persistent symptom, either insomnia or sleepiness, which is not documented on objective testing (nocturnal polysomnography and daytime multiple sleep latency test).

Although the ICSD-2 identified paradoxical insomnia as an independently occurring type of insomnia with symptoms meeting the diagnostic criteria for insomnia for at least 1 month, the ICSD-3 classifies paradoxical insomnia as a clinical and pathophysiological subtype of a chronic insomnia disorder (American Academy of Sleep Medicine 2014). The duration of symptoms required for the diagnosis of chronic insomnia in ICSD-3 became longer than required in ICSD-2, and symptoms must be present for at least 3 months.

In 1976, 2 papers noted the importance of subjectivity in the self-report of sleep in insomnia patients (Carskadon et al 1976; Frankel et al 1976). The subjective sleepiness patient group was first identified following the introduction and standardization of the multiple sleep latency test (Richardson et al 1978).

A review of this concept of sleep state misperception addressed a different subset of individuals who seem to overestimate the amount of time spent in sleep compared to that captured on polysomnography. The authors refer to this group as the “positive sleep state misperception patients,” as opposed to the other, which they call “negative sleep state misperception.” A subclassification of the sleep state misperception or paradoxical insomnia is proposed, to include both ends of the sleep misperception spectrum (Trajanovic 2007). Attarian and colleagues described physiologic wakefulness identified by polysomnography and actigraphy criteria perceived as subjective sleep, which the authors tentatively named “reverse sleep state misperception” (Attarian et al 2004).

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