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  • Updated 05.08.2023
  • Released 09.06.1995
  • Expires For CME 05.08.2026

Paradoxical insomnia



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. Emerging literature has suggested that underestimation of one’s total sleep time has been linked to cases of subjective total insomnia, and sleep wake misperception is relatively common across various sleep wake diagnoses. Treatment of paradoxical insomnia 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.

• Subjective overestimation of sleep onset latency is more common than underestimation in insomnia patients.

• 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 (04) to replace two 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 (02). The American Academy of Sleep Medicine developed Research and Diagnostic Criteria (RDC) for insomnia (03). The RDC criteria also provided three subclassifications of primary insomnia: psychophysiologic insomnia, paradoxical insomnia, and idiopathic insomnia. Other terms used in the past to describe patients with this disorder include subjective insomnia, pseudo-insomnia, subjective sleepiness, and sleep hypochondriasis. The ICSD-3 classifies paradoxical insomnia as a clinical and pathophysiological subtype of a chronic insomnia disorder, and symptoms must be present for at least 3 months.

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). Paradoxical insomnia is characterized by discrepancy between subjective and objective assessments of sleep measure and can be challenging to diagnose and to treat. Furthermore, most studies use a single night of polysomnographic recording to objectively measure sleep onset latency and sleep efficiency, which may not accurately measure an individual’s typical sleep due to high night-to-night variability.

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. For extensive reviews, please see (27; 10).

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