All about Paradoxical Insomnia

According to the NHS, approximately one-third of the UK population will have episodes of insomnia at some point in their life. However, it is thought that only 5% of this number will have paradoxical insomnia, which equates to approximately 1.1 million people in the UK.

The majority of people are aware of insomnia; however, in comparison, very few people have heard of paradoxical insomnia. Today we are going to look at paradoxical insomnia in more detail.

What is paradoxical insomnia?

Paradoxical insomnia (previously known as sleep state misperception) is a sleep disorder which causes an individual to believe they are sleep-deprived, despite having a normal sleep cycle. It is less common than other sleep disorders and causes people to misjudge the amount of sleep they get and the quality of their sleep. For example, they may think they only slept for an hour and that they lay awake for most of the night when, in reality, they slept for seven hours. 

Sometimes referred to as subjective insomnia, someone with paradoxical insomnia may feel like they are awake during their sleep cycle, particularly the non-rapid eye movement (NREM) stages of sleep. This can cause an individual to underestimate the number of hours of sleep they have a night. They often report a heightened awareness of their surroundings while trying to sleep and describe a prolonged delay in the onset of sleep, not falling asleep at all, or poor sleep. However, in reality, the individual experiences typical sleep onset latency and normal sleep quality.

There will be a significant discrepancy between the individual’s subjective reporting of the amount of sleep they get and the objective measure of the duration and quality of their sleep. An individual with paradoxical insomnia will truly believe that they are not getting enough sleep and may experience adverse symptoms. However, evidence, such as the amount of sleep that is shown on a sleep tracker (for example, if they wear a fitness watch or ring) or what they are told by a partner (who may report that they appear to sleep well during the night) will indicate that they are actually sleeping normally. To be considered as paradoxical insomnia, your symptoms should be significant and persistent.

What causes paradoxical insomnia?

The exact cause of paradoxical insomnia is unknown. Although the cause is unknown, it is thought that a combination of factors, including psychological, biological and environmental factors, can contribute to someone developing paradoxical insomnia. These can include:

Hyperawareness/hyperarousal at night

Some people with this condition find they are hyperaware during the night or are over-stimulated at night. This can make it difficult for them to relax or mean they are more aware of their surroundings. They may respond easily to stimuli in their environment; for example, the sounds of their partner breathing next to them can affect their sleep. They may also experience increased mental activity and heightened brain stimulation at night, which can manifest as racing or intrusive thoughts. Hyperarousal can make it more difficult for someone to fall asleep or stay asleep.

Brief awakenings

Many people with paradoxical insomnia awaken multiple times during the night. These awakenings can result in sleep misperception. Having a distorted perception of sleep can cause someone to interpret the brief times they spend awake in the night to be more frequent or longer in duration than they are in reality. It can also cause them to overestimate how long it takes to fall asleep. 

Mental health conditions

In many cases, paradoxical insomnia can occur in conjunction with other conditions. In particular, occurrences of paradoxical insomnia can be related to your mental health or mood. For example, if you are experiencing high stress or anxiety, worrying or feeling anxious in bed can cause you to overestimate the amount of time you spend lying awake.

Paradoxical insomnia can co-occur with the following conditions:

• Schizophrenia.
• Bipolar disorder.
• Alcohol dependency.
• Depression.
• Anxiety.
• Chronic stress.
• Post-Traumatic Stress Disorder (PTSD).

Obstructive Sleep Apnoea (OSA)

This is a condition that causes the walls of your throat to relax and narrow while you are sleeping. This can interrupt your breathing and can result in you gasping, choking or snoring in your sleep. OSA can also cause you to wake up multiple times during the night. Because you are waking up a lot during the night, this can cause you to overestimate the amount of time you spend awake and underestimate the quantity and quality of your sleep.

The signs of paradoxical insomnia

The main sign of paradoxical insomnia is the underestimation of the length of sleep and the overestimation of the number and severity of sleep disturbances.

For example, if you are experiencing paradoxical insomnia, you may report:

• Feeling that you are experiencing acute sleep disturbance or insomnia, while in reality, you are experiencing mild or no impairment. You may feel like you experience:- Difficulties falling asleep (including an inability to fall asleep).
  – Sleep disturbances throughout the night.
  – Little or no sleep.
  – Insomnia.
• Symptoms that are usually consistent with insomnia include fatigue or extreme tiredness, irritability, difficulties concentrating and impaired cognitive performance (in some cases).
• Perceived sleep disturbance with little or no daytime impairment.
• Stress and anxiety, particularly in the lead-up to going to bed.

However, when sleep is measured and analysed, for example during a sleep study, the results usually show that the individual’s sleeping patterns are not abnormal.

The inconsistency between the subjective sleep report and the objective data results in a diagnosis of paradoxical insomnia.

How is paradoxical insomnia diagnosed?

Paradoxical insomnia can be a difficult condition to diagnose. In some cases, a doctor may diagnose this sleep disorder based on your symptoms and other information you provide. This can include a detailed sleep history and information about your recent sleep. To enable you to provide your doctor with more detailed information regarding your sleep, it can be beneficial to:

• Keep a sleep diary.
• Ask your partner (if relevant) about your sleep behaviour.
• Consult an overnight fitness tracker (although this may not be accurate).

However, in other cases, your doctor may refer you to a sleep specialist and you will likely undergo a sleep study. A sleep study, also known as polysomnography, is a special type of study that takes place while you sleep. The sleep study takes place overnight. Before the study starts, the technician will attach sensors to different parts of your body. These sensors will record:

• Your oxygen levels.
• Your brain waves.
• Your breathing patterns.
• The movements of your chest and abdomen.

The sleep study can monitor your sleeping patterns, how long it takes you to fall asleep and identify how frequently you wake up in the night. The sleep study can also examine the quality of your sleep by looking at how long you spend in each sleep stage (e.g. in the non-rapid eye movement (NREM) and rapid eye movement (REM) stages). To be diagnosed with paradoxical insomnia, there should be little or no objective evidence to support your subjective sleep deprivation. 

A sleep study is more likely to be recommended if you have other diagnosed health conditions if previous treatment hasn’t worked or if your doctor is unsure whether you are experiencing insomnia or paradoxical insomnia. 

To be diagnosed with paradoxical insomnia, following a sleep study, your sleep during the study and your perception of your sleep must significantly differ.

The following observations will usually result in a diagnosis:

• Sleeping for an adequate amount of time or having sleep that is judged to be high quality.
• Your actual sleep not being consistent with your sleep perception.
• Significant overestimation of sleep onset latency.
• Significant underestimation of sleep quality.
• Having less impaired daytime function and fewer symptoms that are typically associated with insomnia.
• No evidence of paradoxical insomnia during the sleep study.

Your symptoms of paradoxical insomnia should have lasted for at least one month. 

For some people with paradoxical insomnia, they may still experience adverse symptoms, such as fatigue. Although objectively they sleep for a normal amount of time, their hyperawareness can result in them missing out on the REM sleep stage and, instead, transitioning between Stage 1 and Stage 2 sleep stages, both of which are NREM sleep stages. This can result in them feeling sleep-deprived and fatigued the next day.

The impact of paradoxical insomnia

Even if your sleep is not actually being affected by your condition, paradoxical insomnia can still affect your life in many ways. 

Some people find themselves becoming stressed or anxious in the lead-up to going to bed. They may find it difficult to relax in the evening and experience feelings of dread at the thought of trying to sleep. Paradoxical insomnia can be an emotionally distressing condition. 

Paradoxical insomnia can be a difficult condition to live with. Because you do not show any of the usual signs of insomnia and your sleep isn’t being affected in the same way, your friends and family may not understand what you are going through. Even your doctor may not recognise how debilitating this sleep disorder can be. 

Even if your sleep is objectively normal, feeling like your sleep is significantly disturbed every night can have similar physical and mental consequences as if you were truly experiencing insomnia. This can include stress and anxiety surrounding sleep that affects your day-to-day life. 

Treatment for paradoxical insomnia

There is not one specific treatment for paradoxical insomnia. However, there are multiple treatment options available. The treatment option that will be most effective can depend on multiple factors, including the cause and severity of your sleep disorder. In some cases, you may have to try multiple different treatments before you find the one that works best for you. 

The treatment options for paradoxical insomnia include:

Cognitive Behavioural Therapy for Insomnia (CBT-I)

CBT-I can be an effective treatment for both insomnia and paradoxical insomnia. It can help you to identify any thoughts, feelings or behaviours that are causing or contributing to your sleep disorder. It can also help you to identify the root cause of your condition. CBT-I can also address the stress and anxiety that you experience, as well as any dysfunctional thoughts, such as ‘I’m never going to fall asleep’ or ‘I’ll be awake all night and too tired to function in my meeting tomorrow’.

Sleep Education

Many people hold misconceptions about sleep that can contribute to paradoxical insomnia. These can include inaccurate information about sleeping patterns, sleep behaviour and sleep health. Sleep education can teach you healthy behaviours that can help to improve your sleep, such as focusing on your evening routine, decreasing your screen time and focusing on your mental and physical wellness. Sleep education can also help to reduce any anxiety you are feeling around sleep and teach you how to improve your sleeping environment.

Relaxation Techniques

Relaxation techniques can help to reduce stress and anxiety, relieve the tension in your body and help you to feel more calm, relaxed and in control.

Some relaxation techniques you can implement in your day-to-day life include:

• Deep breathing: Deep breathing is an effective way to lower your stress levels, relieve tension in your body and reduce anxiety and panic. Deep breathing sends a message to your brain to relax. Practising deep breathing as part of your daily routine can help to improve your symptoms, particularly because deep breathing can increase your melatonin levels, promoting relaxation and sleep.
• Meditation: Meditation can teach you how to control your breathing and manage your body’s response to stress, anxiety and dysfunctional thoughts. Meditation helps to relax your body and brain and distract your thoughts. It can also help to reduce your cortisol levels, which is associated with heightened stress, and increase your melatonin levels, which can help to improve your sleep.
• Progressive muscle relaxation (PMR): PMR can be helpful for people with insomnia and paradoxical insomnia. It involves gentle breathing and systematic tending of groups of muscles. This can help to relax your body and relieve any tension you are feeling.
• Autogenic training: This relaxation technique is designed to relax the body and reduce anxiety. Specific phrases (e.g. ‘My legs are heavy, I am completely calm’) are repeated to help create a calming sensation in different areas of the body. Autogenic training is a type of self-hypnosis which helps you enter a relaxed state and encourages feelings of heaviness and warmth in your body.

Is paradoxical insomnia different to insomnia?

Insomnia is a sleep disorder that is categorised by consistent difficulties with the onset of sleep, maintaining sleep, sleep duration or sleep quality. Insomnia makes it difficult to fall asleep, stay asleep or have good quality sleep. It often causes impaired daily functioning. 

Individuals with insomnia may also report a discrepancy between the amount of time they think they sleep (subjective sleep) and the amount of time they actually sleep (objective sleep). However, this discrepancy will be significantly smaller, compared to those with paradoxical insomnia. 

The main difference between insomnia and paradoxical insomnia is that an individual with insomnia is genuinely experiencing sleep dysfunction whereas an individual with paradoxical insomnia is perceiving a dysfunction, rather than experiencing it in reality.