Paradoxical Insomnia: Causes, Symptoms, and Treatment

Treating a patient who has insomnia can be challenging. When the patient insists they haven’t slept in weeks despite evidence to the contrary. It’s frustrating enough. And yet, regardless of your best efforts, they continue to claim that they cannot sleep.

The patient is insistent that they cannot sleep, despite their partner’s assertions that they appear to be asleep or even snoring. Potentially, the patient is experiencing paradoxical sleeplessness.

If you’re having trouble sleeping but look well-rested, you may have paradoxical insomnia.

Paradoxical insomnia is a disorder in which a person believes they haven’t been sleeping well, even when bodily markers and diagnostic testing show they are. This syndrome is also called sleep state misperception.

To put it another way, paradoxical insomnia leads people to underestimate the sleep they are getting drastically. Up to fifty percent of those who struggle with sleeplessness also have this condition.

The causes, symptoms, and treatment of paradoxical insomnia are discussed in this article.

Paradoxical Insomnia

Paradoxical Insomnia

Paradoxical insomnia (formerly sleep state misperception) causes heightened alertness during sleep. If you have this disease, you may find that even after a good night’s sleep, you still feel drained the next day.

There has been a need for more progress in understanding paradoxical insomnia. This is because of disagreements about quantifying objective and subjective sleep duration. Also, the prevalence of paradoxical insomnia is difficult to assess because it ranges from 8% to 66%, according to one review, depending on the parameters utilized in sleep tests.

Paradoxical insomniacs have a higher subjective-objective sleep time gap than other insomniacs (often called objective insomnia in clinical settings).

Several symptoms, such as those associated with objective insomnia, are reported by patients with this disease. This is even though they sleep for a reasonably normal amount of time and are only mildly impaired throughout the day.

Stress levels appear to be raised in the same proportion by paradoxical insomnia as by objective insomnia.

Causes Of Paradoxical Insomnia

There has been no discovery yet of what triggers paradoxical insomnia. However, some study has linked it to psychiatric diseases and showed brain activity changes, which may explain its etiology.

Paradoxical insomnia patients’ brains were examined in a 2021 study. Brain areas involved in sleep awareness and circadian rhythm regulation changed.

According to a 2020 study, psychological or personality factors may have contributed to its onset. Paradoxical insomnia is more common in those with anxiety and depression.

Research links paradoxical insomnia to neuroticism. These traits and anxiety and arousal need further study.

Paradoxical insomnia may be caused by undetected brain circuitry differences. Studies show that paradoxical insomniacs have abnormal brain activity during sleep, indicating wakefulness.

Paradoxical Insomnia and Other Disorders

Paradoxical insomnia is a sleep disorder where individuals perceive themselves as being awake when they are asleep. This disorder can coexist with other sleep and nonsleep disorders, such as anxiety, depression, and substance abuse. Other sleep disorders, like insomnia and sleep apnea, can also coexist with paradoxical insomnia.

This implies that the emergence and maintenance of paradoxical insomnia may be influenced by many underlying causes. Individuals with paradoxical insomnia and other co-occurring conditions may benefit from a comprehensive treatment approach that targets both the sleep and nonsleep aspects of their disorder.

1. Obstructive Sleep Apnea

Obstructive Sleep Apnea

Sleep breathing disorders like obstructive sleep apnea (OSA) can cause people to overestimate or underestimate their sleep time.

2. Depression


Insomnia is a typical symptom of depression. But some persons with severe depressive illness also have a mismatch between their perceived and actual sleep duration.

3. Post-Traumatic Stress Disorder (PTSD)

Post-Traumatic Stress Disorder (PTSD)

Paradoxical insomnia may play a part in PTSD-related sleep trouble. Studies have found little variation in sleep between those with PTSD and a control group. An estimated 70% of patients with post-traumatic stress disorder have sleeplessness.

4. Irritable Bowel Syndrome

Irritable Bowel Syndrome

IBS is a gastrointestinal disorder linked to sleep disturbances. Studies suggest that IBS patients may underestimate their sleep time, leading to a mismatch between perceived and actual sleep duration.

Symptoms of Paradoxical Insomnia

Symptoms Of Paradoxical Insomnia

Better understanding is needed for sleep disruption. However, 5% of people misperceive their sleep condition, with young to middle-aged people being the most affected.

However, SSM patients’ good mental and physical health may indicate that the disease is underreported.

Paradoxical insomnia symptoms include:

  • Severe insomnia
  • Having slept for a short time or not at all, or feeling as though you haven’t slept for years.
  • Being otherwise (psychiatrically and medically) healthy and free from the degree of impairment typically associated with such a level of sleep loss.
  • Increased awareness of surroundings when lying down.
  • Having trouble remembering your thoughts from the previous night after having too much sleep.

On the other hand, several signs and symptoms can characterize insomnia:

  • Falling asleep after more than 30 minutes.
  • Nighttime awakenings that make it difficult to get back asleep.
  • Waking long before your desired time.
  • Weariness, irritability, sleepiness, or a lack of energy during the day.
  • Less than seven hours of sleep per night.

Diagnosis of Paradoxical Insomnia

Diagnosis Of Paradoxical Insomnia

Your primary care physician would probably recommend seeing a sleep doctor if they suspect you have paradoxical insomnia. Sleep studies, commonly known as polysomnograms, are what the doctor will conduct.

The tests (“poly”) are extensive and include monitoring vital signs. This includes breathing, heart rate, oxygen levels, and physiological functions, including eye movement.

The sleep doctor will also do an electroencephalograph (EEG) to record brain electrical activity. These measures reveal your sleep time, quality, and frequency when combined.

The following criteria must be met to receive a diagnosis of paradoxical insomnia from a medical professional:

  • Spend an average of 6.5 hours or more in slumber each night.
  • To achieve a sleep efficiency level of 85 or better.
  • Perform better during the day than someone who has insomnia.
  • You’ve been sleepless night after night for at least six months.

Paradoxical sleep is diagnosed by a sleep doctor based on your perceived lack of sleep and objective measures of sleepiness.

In most cases, a comparison of subjective and objective evidence is used to diagnose paradoxical insomnia. However, if the clinical complaint is particularly severe, a clinical interview alone may be sufficient to make the diagnosis.

Treatment of Paradoxical Insomnia

Treatment of Paradoxical Insomnia

Contrary to popular belief, paradoxical insomnia can be treated in various ways. Those who think they may have paradoxical insomnia should consult a doctor for an accurate diagnosis and the best course of treatment.

Drugs, including antipsychotics and sleep aids, have been used to combat paradoxical insomnia. Unfortunately, while their potential benefits outweigh their risks, clinicians have no agreement on whether they are beneficial.

Sleep education, including relaxation and sleep hygiene, can treat paradoxical insomnia. Sleep education sessions that accompany sleep studies very frequently focus on the disparity between a person’s self-reported and real sleep time.

Cognitive behavioral therapy is an alternative treatment that helps patients identify and change negative thoughts and behaviors.

Cognitive behavioral therapy for insomnia improves sleep quality and duration, suggesting it may potentially help paradoxical insomnia.

When trained extensively, people can overcome the cognitive bias that “trying to sleep” makes it more difficult to doze off. If you’re having trouble sleeping, practicing excellent sleep hygiene (staying awake in a calm, quiet environment) may help.

Until you feel sleepy, continue to sleep.

When it’s time to go to bed, mute all the sounds and lights and climb.

Lie in bed and relax without attempting to sleep. Instead, try to remain calm and have passive awareness while sleeping with your eyes closed.

To stop trying to fall asleep, you can also try the following:

  • progressive muscle relaxation
  • guided visualization
  • breathing techniques

Practice will help you fall asleep faster and normally sleep, making remaining up a more desirable alternative and reducing your sleep anxiety.

Sleep education is another name for this behavioral treatment. Its efficacy has been repeatedly demonstrated, and there are no known dangers or negative consequences. However, consult a sleep doctor if you need help getting to sleep or staying asleep.

If your doctor or psychologist has had specific training in sleep medicine, they may be able to help you with this treatment.

Parting Note

Paradoxical insomnia is a real and unpleasant problem, even if it is still a disorder that has received very little attention—sleep perception discrepancies cause this disorder, which overlaps symptoms with chronic insomnia.

Some people experience paradoxical insomnia, and it’s important to understand that there are treatments that could assist. A mental health practitioner specializing in cognitive behavioral therapy may prove useful.

Sleep hygiene is otherwise essential to physical and mental well-being. Improving your sleep quality may help establish good routines before bedtime.

Behavioral therapy and sleep education are effective in managing and treating paradoxical insomnia. Staying up for a long time can help you fall asleep more quickly and easily because it relieves the stress associated with staying awake.

In severe cases, standard treatment protocols may be followed. This includes the use of conventional antipsychotic medications and benzodiazepines. But, if you want professional help, you should talk to your doctor or ask to be sent to a sleep specialist.

Sarah Wagner

I'm Sarah Wagner, and I founded Sweet Island Dreams in 2022. It's a blog dedicated to helping people mental vacation virtually anytime they want. By providing information about the best sleep of your life, I help people drift away to paradise without ever having to leave their bed!