A PARADOXICAL KIND OF INSOMNIA
Despite feeling like I hadn’t slept for much of last night, my Fitbit tracker indicated I’d actually gotten about seven hours of sleep. Thankfully, this discrepancy doesn’t occur often—perhaps once a month. I’ve since learned that this phenomenon is known as paradoxical insomnia.
A recent write-up in Scientific American’s online Today in Science, titled “Up All Night,” published on June 10, 2024, discusses this condition. Here are some highlights from that short article:
People with paradoxical insomnia (also called subjective insomnia) report that they’ve been awake all night, even when the polysomnography, the gold standard for sleep measurement, says they’ve been asleep. Now, scientists have taken more extensive measurements of the condition and found that this type of insomnia involves spurts of arousal–fast brain waves–during rapid eye movement (REM) sleep.
The typical “quiescent” state of REM (immersive dream state) dissolves emotional distress that has accumulated throughout the daytime. People who experience interrupted REM never reach a deep state of REM and report poor sleep (though technically they have been sleeping). “Sound REM sleep is the only state during which the brain has a ‘time-out’ of noradrenaline [norepinephrine],” which is a stress hormone, says Eus van Someren, a sleep scientist at the Netherlands Institute for Neuroscience. “The neurons are not firing anymore, so they don’t release noradrenaline downstream in the brain.”
That’s intriguing, I told myself. So I hunted for more information. I found it in a January 2, 2024 SleepFoudation.org article by Jay Aummer, Staff Writer, and Dr. Abhinav Singh, Sleep Medicine Physician, titled Paradoxical Insomnia: The Misperception of Your Sleep State. Here are excerpts:
Sleep is a complex process, and sometimes our perception of how well we sleep — or even whether we are asleep or awake — can be incorrect.
What Is Paradoxical Insomnia?
Insomnia is a sleep disorder involving persistent difficulty with sleep onset, duration, or quality. Paradoxical insomnia, on the other hand, is named after its central paradox, which is that people with this condition believe they have stayed awake for most of the night despite sleeping for close to a normal length of time.
The study of paradoxical insomnia has been hindered by a lack of consensus on the quantitative definitions of objective versus subjective sleep duration. One review found that the prevalence of paradoxical insomnia ranged from 8% to 66% depending on the parameters used in sleep studies, making it difficult to estimate its rarity.
People with insomnia — sometimes referred to as objective insomnia — often experience a discrepancy between their perception of sleep duration and the amount of time they were actually asleep, but the difference between subjective and actual sleep duration is particularly marked in people with paradoxical insomnia. Despite sleeping for a relatively average length of time and experiencing limited daytime impairment, people with this condition report many of the same symptoms as those with objective insomnia.
Paradoxical insomnia also appears to raise stress levels to a similar degree as objective insomnia.
What Causes Paradoxical Insomnia?
Experts are unsure of what causes paradoxical insomnia. One theory is that it may be caused by differences in the neural structure of sleep that are unable to be detected by current methods. Compared to both people without insomnia and people with objective insomnia, studies show that those with paradoxical insomnia display altered brain activity indicative of arousal during sleep.
Paradoxical Insomnia and Other Disorders
Paradoxical insomnia may occur alongside other disorders, both sleep-related and otherwise. These include: obstructive sleep apnea, depression, post-traumatic stress disorder (PTSD), and Irritable bowel syndrome.
Symptoms
People with paradoxical insomnia report feeling aware of their surroundings at night and sleeping for only a few hours each night, if at all, despite objectively sleeping for long enough to avoid sleep deprivation symptoms.
Another potential symptom of paradoxical insomnia is experiencing sleeplessness without significant impairment the next day. However, some people with the disorder do report feeling daytime fatigue. Paradoxical insomnia may also cause sleep disturbances over time due to the distress caused by the perceived lack of sleep.
How is it Diagnosed?
Since a diagnosis of paradoxical insomnia requires confirmation that someone is sleeping when they think they are awake, the diagnosis is usually made after a sleep study. Also known as polysomnography, a sleep study allows doctors to objectively confirm when a person is asleep or awake, which can then be compared against their self-reported sleep length.
It is also possible to diagnose paradoxical insomnia using actigraphy, a form of sleep analysis that involves wearing a wristwatch-style device while at home [Like my Fitbit?]
Treatments
While there is no standard treatment protocol for paradoxical insomnia, there are potential options. People who suspect they have paradoxical insomnia should speak with their medical provider, as they will be able to prescribe the most appropriate treatment once they have made a diagnosis.
Medications, including sedatives and antipsychotics, have been used to treat paradoxical insomnia. However, they may have side effects, and there is a lack of clinical consensus regarding their effectiveness.
Other treatments for paradoxical insomnia include sleep education and guidance in sleep hygiene and relaxation techniques. Sleep education is sometimes provided in conjunction with a sleep study, in which the study participant and a doctor review the results and discuss the discrepancy between perceived and actual sleep duration.
Another treatment option is cognitive behavioral therapy, which uses a combination of therapeutic techniques to identify negative thought patterns and behaviors and replace them with helpful alternatives. Studies focused on the use of cognitive behavioral therapy for people with insomnia indicate that it can improve both sleep quality and perceived sleep length, making it a potentially useful treatment for paradoxical insomnia as well.