Paradoxical Insomnia: Do You Sleep Better Than You Think Do?

man sleeping in bed with his partner next to him also asleep

Do you sometimes wake up feeling like you hardly got any sleep? But after a shower and breakfast, you’re surprisingly alert and manage to get through the day just fine?

This happens to me more often than I would have once admitted. And even though I know it happens, it’s not always easy to accept that I often actually sleep considerably better than I feel I do.

Asleep or awake?

Surely the heavy eyes and the sore head are clear signs of a terrible night’s sleep? And what about the feeling that I woke up many times, only sleeping lightly between wakings?

On the other hand, I’m not exhausted by midday, I’m able to get my work done, go the gym, and power on through the day without being a horribly grumpy human being.

So what’s going on?

Am I just used to living with insomnia? Do I dream about being awake? Am I just really, really bad at judging how much sleep I get?

It turns out that the truth is probably a combination of the first and third explanations. There are occasional nights when I genuinely don’t sleep much: if I get up and start working at 5 a.m. I’m definitely not asleep!

But more frequently, I also have what’s known as paradoxical insomnia.

What is paradoxical insomnia?

paradoxical insomnia definition in a graphic

Paradoxical insomnia is a subtype of insomnia. It used to be called sleep state misperception or subjective insomnia.

It involves a discrepancy between how much a person feels their sleep is disturbed and what can be objectively observed.

So even though someone might report that they have a serious sleep problem, a polysomnogram test in a sleep clinic would show key points like they fell asleep quicker, slept for longer and woke less than they thought.

And so it follows that people with paradoxical insomnia don’t usually have a serious problem with daytime functioning either.

So in essence, you think you were awake when you were really asleep. And so you underestimate how much total sleep you have.

How common is it?

Paradoxical insomnia still isn’t fully understood by sleep experts, and estimates of how many people have it vary.

An often quoted statistic comes from the Handbook of Sleep Disorders, which puts the figure at 5% of the population – mostly young to middle-aged adults.

An experiment in Korea in 2015 tested 250 adults with a diagnosis of primary insomnia. And they found 26.4% of those actually had paradoxical insomnia – judged as sleeping more than 6.5 hours and having at least 85% sleep efficiency.

It’s also useful to note that researchers have found that not everyone with insomnia underestimates their sleep. Some even overestimate how much sleep they get!

paradoxical insomnia infographic

How it’s diagnosed

According to the International Classification of Sleep Disorders, it needs to have been present for at least 3 months.

An overnight sleep study in a sleep center will find no evidence of a sleep disorder. And it will show that key sleep parameters, such as how long it takes to fall asleep, number of wakings, and total sleep time, are within normal limits.

Importantly, a patient will show evidence of an overestimation of how long it takes them to fall asleep. And an underestimation of sleep efficiency, such as how often and for how long they wake in the night.

There also needs to be no evidence of malingering or psychopathology.

However, not everyone has access to a professional sleep study. So there may be times when your personal doctor considers the possibility of this diagnosis.

For another story of a patient who was diagnosed with this following a polysomnogram sleep study, take a look at the article on the American Family Physician website.

How wrong does your estimation of your sleep need to be for a diagnosis to be given?

A team of researchers published an interesting paper on paradoxical insomnia in 2019.

They talk about issues regarding the boundary of paradoxical insomnia. For example, how big should the difference be between the time you think you slept and the time you actually slept for a diagnosis of paradoxical insomnia to apply?

It’s a good question, and it seems that there isn’t one-size-fits-all answer globally. As they say:

The current understanding of paradoxical insomnia and, more broadly, of sleep state misperception, is greatly hampered by the lack of agreement on a quantitative and evidence-base measure of the discrepancy between subjective and objective sleep evaluation. 

Hopefully, their research will inspire more efforts in the future, as it seems that for now, the diagnosis will depend in part on where you’re tested.

Is there something wrong with me?

When I first found out that I had paradoxical insomnia, something bothered me about it.

If I can’t even tell the difference between being awake and being asleep, surely there must be something wrong with me?

Being someone prone to anxiety, it’s perhaps unsurprising that I’d find a way to worry about the fact that I apparently had nothing to worry about.

If this is something that concerns you too, the short answer is not to label yourself as a hypochondriac just yet.

Clearly, something isn’t quite right if your sleep time causes you significant distress. But it doesn’t necessarily mean something is ‘wrong’ with you, or that it’s all in your head either.

The long answer is, of course, more complex. And I think it’s helpful to start with how sleep researchers point out that it’s not a condition to trivialize or dismiss.

Why paradoxical insomnia should be taken seriously

According to Allison Harvey at Berkley University, in her review of paradoxical insomnia theories, there are good reasons to understand the condition better.

She makes an interesting comparison with depression. People who say they feel depressed don’t need to prove it objectively. So why should people who say they sleep badly have to prove it?

If a doctor thinks the patient doesn’t have insomnia, care needs to be taken not to dismiss them just because a sleep study says nothing is wrong. Interestingly, Allison suggests that sleep studies might not be picking up on the reason people feel they sleep badly.

Secondly, some people might have both an underestimation and a lack of sleep. If they think they only slept for 2 hours, but actually slept for 5, it’s still not enough sleep for most adults.

This is, in fact, something I now know happens to me. It’s common for me to think I only got 3 or 4 hours’ sleep. But my sleep trackers will often show on those nights that I slept for 5 or 6. So although my guess is off, it’s still not enough sleep (assuming I can trust the sleep tracker data).

Worrying about not sleeping can then affect your sleep

Also important is the effect of constantly worrying about your sleep. As Means and Edinger point out in their study, worrying about a lack of sleep might cause a lack of sleep.

For me personally, this last point is important, and one I definitely relate to.

After a couple of nights of feeling like I didn’t sleep so well, anxiety that it will happen again can hit me hard. And that anxiety genuinely makes it more difficult to relax and fall asleep.

For this reason, some suggest this form of insomnia could be a transitional form of insomnia, eventually turning into chronic insomnia.

And that has important implications for treating paradoxical insomnia. If it’s not ‘nipped in the bud’, so to speak, then it might get worse. Helping people understand their sleep, and cope better, is therefore important.

What causes paradoxical insomnia?

paradoxical insomnia causes infographic

The exact cause still isn’t fully understood, but is a source of ongoing research.

In Allison Harvey’s review, she considered 13 different explanations, finding stronger evidence for three in particular:

1. Perceiving sleep as being awake

In a study in Australia, insomniacs and normal sleepers were woken up when they were definitely asleep. The researchers found that insomniacs were more likely to say they were already awake rather than asleep.

So a difficulty in telling the difference between being awake and asleep will contribute to an underestimation of your total sleep time.

2. Worry

Many people worry about getting enough sleep. And that worry then distorts a person’s perception of how long it really took them to fall asleep.

In addition, people might then pay more attention to signs they didn’t sleep well: checking the clock in the night; waking with heavy eyes and a sore head; noting how tired they feel in the day.

That selective attention and monitoring, as it’s known, might then fuel the worry even further.

3. Transient/brief wakings

People with paradoxical insomnia might have more short wakings in the night – between 3 and 30 seconds at a time. And then misinterpret how long they were awake for each time.

One experiment showed this effect with volunteers wearing a mask that induced more short wakings. The more there were, the more likely people were to further underestimate their total sleep time.

Other factors

In addition to those three possibilities, the review also mentioned other interesting theories. For example:

  • The process of falling asleep is ripe for misinterpretation. For example, our memory is less effective, and there’s less stimulus in the quiet, dark bedroom.
  • Physiological changes can affect the way we think. And that might make it harder for us to tell when we were awake or asleep.
  • Parts of the brain usually active when awake and asleep might both be active at the same time.

Interestingly, some recent research studies have looked more closely at the third option.

Differences in brain activity when sleeping

A study in 2017 investigated which areas of insomniacs’ brains were active during their sleep.

They found that at times when insomniacs mistook sleep for wake, parts of the brain associated with conscious awareness were more active than normal sleepers.

Professor Kay, the team leader, reported in Medical News Today:

In patients with insomnia […] processes involved in reducing conscious awareness during sleep may be impaired […] One of the strategies for targeting these processes may be mindfulness meditation.

In 2018, researchers in Taiwan also found evidence for a difference in brain activity. In the study, 36 adult volunteers were woken after a set period in which most had fallen asleep.

Incidences where people reported being awake, instead of asleep, were associated with lower theta power, as well as higher alpha, beta, and gamma power.

And back in 2001, researchers reviewed seven studies in which this type of brain activity was found.

In those studies, brain activity monitoring with EEG showed more Beta to Gamma brain activity. Activity which is usually associated with the waking brain, such as attention, perception, and memory.

These neurological findings suggest that brain hyperarousal in some insomniacs might also play a key role in why they feel they are awake.

Which is the most likely explanation?

So there appear to be several psychological, physiological and neurological explanations for paradoxical insomnia.

As Allison Harvey pointed out, one day just one of those explanations might be found to be the key. But it’s also possible a combination of several will be settled on.

It could be that the distinction between sleep and wake in terms of brain activity isn’t as simple as an on/off switch – especially for those with paradoxical insomnia.

And if you remain a little more conscious than most people, that might increase the chance you feel you’re awake.

Feeling that you’re not sleeping well might then trigger feelings of anxiety and worry about sleep. And that then pushes you into the classic vicious circle of worrying about sleep being the reason you can’t sleep.

Going back to the question of whether there’s something wrong with you, the above research does provide some comfort – for me at least.

I don’t mind thinking my brain is a bit more active at night and that I’m just a worrier. That’s better than wondering why I’m apparently incapable of knowing if I’m asleep or awake. And with that, questioning my grip on reality.

Treatment options

As researchers in 2018 wrote, there’s no standard treatment for paradoxical insomnia:

there is a paucity of literature about [the] treatment of sleep discrepancy and paradoxical insomnia. Therefore, the underlying neurophysiological mechanisms of sleep discrepancy and paradoxical insomnia should be further investigated.

In 2011, researchers tested the potential for behavioral therapy with 4 patients. They provided education about the difference between their sleep study results and their perception of how much they slept.

Two people responded well to this treatment, but it didn’t appear to help the others. Still, it showed promise as a treatment. And Cognitive Behavioral Therapy for insomnia is a popular treatment option.

Unfortunately, educating people with a sleep study and one-to-one time with a sleep expert is an expensive and time-consuming option that few will have access to.

A study by Tang and Harvey in 2006 also tested the idea of comparing a manual sleep diary with an actigraph sleep tracker. They found positive results with this technique, but again, it worked best with professional guidance.

Even though both a sleep diary and sleep tracker can be easily obtained, it would take dedication on behalf of the patient. And faith that the tracker is accurate – an issue that’s hotly debated.

Perhaps a more practical solution for the individual is to work on underlying factors like anxiety and tension. Tackling anxiety is something anyone can try, either with professional help or self-help.

My personal way of coping

Just knowing more about this form of insomnia helped me a great deal. As did accepting that I’m prone to worrying and excessive rumination.

Some of the practical things I do to help are:

  • I have no clock in the bedroom. My phone is my alarm, and I switch it off at night, as the alarm will turn it on again.
  • Don’t dwell on any physical feelings in the morning. I often wake with ‘hot eyes’ as I call it. I try to ignore this and not see it as a sign of bad sleep.
  • I started making major efforts to tackle stress and anxiety in my life. I practice mindfulness meditation and yoga, go the gym regularly, eat healthily, talk about my problems more, and don’t do stressful things at night.
  • I practice good sleep hygiene, such as no caffeine in the evening, have a consistent bedtime routine, create a comfortable bedroom.
  • If I feel like I’m awake in the night, I remind myself not to stress about it. I do some simple relaxation/meditation exercises, and that usually helps.
  • If I’m convinced I slept badly, I try not to let it affect my day. I remind myself that very often, a shower, good breakfast, and coffee fixes the blurry feeling when I first wake up.

Your thoughts

Have you been told you have paradoxical insomnia? Or is it something you suspect you have? What do you feel helps you sleep better?

Please share your experience and thoughts in the comments below.

24 thoughts on “Paradoxical Insomnia: Do You Sleep Better Than You Think Do?”

  1. I remember my first night of insomnia in August 2017 as if it was yesterday. I was 27 years old with such a love of life. I was in Lyon in France for vacation… since then I’ve been struggling with acute insomnia, and since then I miss my life. I’ve tried everything, I really mean everything… medication (the only one which works was a neuroleptic (methotrimeprazine), but I had to stop it because I really felt bad during the day), I’ve tried also hypnosis, acupuncture, ayurveda medicine, weighted blanket, CBT etc.) without success…
    I went to a sleep center in switzerland this summer (I’m swiss, sorry for my mistakes) and slept one night. And then the doctor told me that I’ve got paradoxical insomnia. I couldn’t and still cannot believe him and neither my boyfriend who is a witness of my nights and of my nightmare… It’s not that I don’t want to believe the doctor but It just doesn’t make sense.
    Three weeks before my night in the center I had to stop my sleep medication and I was given an actimetrics watch to observe how I sleep. I told the doctor and the psychologist of the center that I’m use not to move a lot in my bed even if I’m awake. I prefer to meditate and wait. That’s why I ask them if I had to move and do something else like reading. They answered “no, do as usually”. So I stayed in my bed during my insomnia… What a mistake…. Because of these three weeks (of real torture) and because of my night in the center (it showed I fell asleep in 11 minutes and that I slept 5 hours (had the feeling I slept only 2 or 3) they said I suffer from paradoxical insomnia…
    Few months later I asked them to do the actimetrics again. I told them I would move when I don’t sleep to show them my reality. They accepted. And that time they could have observed that I really have a bad sleep (4 hours and really not continuous), but because of my first experience they say that my sleep has been becoming worth which is not true. It’s just that I moved instead of staying in my bed….I would prefer thousand times to sleep without knowing it…
    My dream is to sleep and for about one year I had to stop working because of my sleep deprivation.
    More studies are needed to look at the sleep of people who supposedly sleep and don’t feel they are sleeping and really feel exhausted by their night and their lack of sleep. We need to get an answer and to have a solution… Thanks for reading

    1. Hi Emma
      Thanks for your comment and for sharing your experience. I can understand your frustration, both because of the sleep problems and the response you got from the sleep study. I would suggest seeing a different doctor or sleep specialist for a second opinion. If your sleep problems have disrupted your life that much and for so long, I think it’s a good idea to see what a fresh perspective might offer.

  2. I have this is as well. I’m curious if there was a specific event that triggered anyone’s paradoxical insomnia? I know what my event was but others may have different triggers. It seems odd that it would just happen suddenly for a home. . I can’t seem to find any research into that. It surprises me that this wouldn’t be studied more in order to find the root of it.

    1. Hi Jen
      If there was a specific event for me, I definitely don’t know what it was! It would be nice if there was, and I knew what it was, as then I might be able to work on that.

    2. I have had paradoxical insomnia and chronic insomnia for 6 years. Mine started when I watched someone die in their sleep. My brain associated sleep meant death so my survival mode kicked in and hasn’t stopped. I am never “tired” but never refreshed. I am still looking for that one thing to kick it back.

      1. Hi Kevin
        That must have been traumatic on some level for you. Have you spoken much about it, or considered a talking therapy? Perhaps that might help to undo the damage done with that association.

  3. Paradoxical insomnia began for me the day I started Zoloft. Within those four days mild anxiety turned into terror and panic attacks. Two years later and nothing has changed. I know I don’t sleep enough either despite not being able to perceive it. I wonder if any others out there can link their paradoxical insomnia to an adverse med reaction?

  4. I was diagnosed with paradoxical insomnia 6 years ago and I have been searching that long for an answer I have tried everything you can think off from acupuncture, all the drugs you can think off, even 15 ect sessions, but nothing seemed to work. What I read makes perfect sense. 1 way of proving I was asleep was I recorded myself. I have in the 6 years suffered from parallels and fight-flight and freeze. I am also in survival mode, I am so desperate to have good nights rest 6 years is a long time to be tortured.

    1. Hi Kevin
      Thanks for sharing your story. It sounds like you’ve been through a lot. I hope the article helped, and that you can find something on my blog that helps you sleep a little better. If medical treatments didn’t help, perhaps a talking therapy might be a positive avenue to explore?

  5. This could be me. I fall asleep without issue but I then feel like I am dreaming constantly like someone has left a TV on playing back to back programs. I wake frequently and in the morning I feel exhausted. However, once I am up I am not tired. I have sleep paralysis occasionally and my dreams vary from mundane things to very distressing ones. Both types of dreams eventually wake me up. However, my Fitbit says I have slept more than I feel. I was about to throw it in the bin as I thought it was broken. I am really interested how to combat this as it is very draining. All advice welcome I will try almost anything lol

  6. This is so reassuring!
    I suspected something like this – my mind just doesn’t shut off. I’ve suffered insomnia since I was about 16 – I’m now in my seventies! I do sometimes not sleep ( I’m up or reading all night) and the feeling the next day is so different from what I feel after my ‘normal’ insomnia. My partner often reported that I had been sleeping when I thought I hadn’t. This explains it and I think this information, with some mindfulness, might reduce the effect. I’ll also try CBTI.

    1. Hi there
      I’m glad the article was useful for you. Mindfulness is a great way to explore different techniques for coping with anxiety and stress about sleep. And just for life in general I find it’s helpful!

  7. I found an app called Sleep On Cue and it was developed by a licensed Sleep Technologist. He has 20 years of experience and his app actually works. I have Paradoxical Insomnia and this app trains your body to remember what falling asleep feels like. It really helped me tremendously! I was doing well for a while, but due to stress, I started having trouble again and I wasn’t using the app. I’m starting to use it again to get myself back on track. The app only cost $4.99. Just look it up on your phone!

    1. Hi Sara
      Thank you for your comment and suggestion – I am going to take a look at the App.

  8. I am a kid with paradoxical insomnia and it sucks. With also being transgender, it leaves a lot of stress. So when I try to sleep, all my stress says,”HEY YOU KNOW WHAT WE SHOULD DO WE SHOULD SLEEP ALL NIGHT AND THINK WE ARE AWAKE” and it is frustrating. Some things I do are…

    •Play out a scenario in your head.
    •Think of what you’re going to do the next day.
    •Put your phone on night shift and play on it.
    •Put in earbuds/ headphones and listen to soft, sweet music like Cavetown or Shiloh.

    I hope this helps!

    1. Hi Matt
      Thanks for your comment and for sharing your sleep tips. I think all of them are good ones, though I’d avoid thinking about stressful things the next day. Thinking of a relaxing scene and/or listening to relaxing music would be my top choices in your list.

    2. Anyone try the app? Looking for feedback on it. Looking for a cure.

      I have had this same problem of feeling awake for over 20 years. Ambien helps a little. Dreams are vivid too. Sometimes I feel like I’m laying in bed thinking weird thoughts but those are probably dreams. Sometimes I think “oh I’ll just lay here a little longer and keep trying”. But several hours have gone by. There’s no wave or rush of darkness signalling the onset of sleep. I remember that feeling from when i was a kid.

  9. This is the first time I’ve heard of this, and I’ve had numerous sleep studies done. It’s true though! I will feel like I’ve been struggling to sleep all night, wake up exhausted, and it doesn’t register on a sleep study. My husband swears I’ve been snoring all night. This makes sense. Thank you for the information, Mr. Green…

    1. Hi sablegirl
      You’re very welcome! It would be interesting if you can get back in touch with the sleep center to ask them their opinion. Does you snoring come up in sleep studies? I imagine they checked for sleep apnea if you’re a regular snorer.

  10. This really sounds like me, I’ve never had a sleep study but I very often say to my partner I’ve not slept a wink and he tells me he’s heard me sleeping he’s gone to bathroom etc and I haven’t heard him. Then my mother used to tell me the same as have friends in the past , thanks it’s put it in perspective

    1. Hi Tracey
      Thanks for your comment. And in turn, that sounds like me! It’s funny how other people sometimes have a different view of our sleep. Of course, unless they are awake all night, they won’t have a totally accurate picture either. But it can help to reassure us that we did get some sleep.

  11. Solange Kindermann

    Thank God for this article! For months I thought I had insomnia, and now I know I have the paradoxical type only. How nice to know and stop wondering what’s wrong with me. Thank you very much.

    1. Hi Solange
      Thanks for your comment, and I’m happy to hear the article was useful.

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