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 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!
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?
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.
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.
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.
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.
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.