Paradoxical insomnia may respond to treatment with CBT & therapies lowering arousalParadoxical insomnia: a diagnosis given to people whose sleep studies show they sleep a normal amount but who perceive they sleep much, much less. When I wrote about it in 2015, the word was that cognitive behavioral therapy (CBT)—the gold standard in treatments for insomnia—might not be an effective treatment for it.

But a brief testimonial that recently appeared in American Family Physician argues otherwise. Here’s an update on this puzzling sleep disorder.

A Subjective-Objective Discrepancy

Time and again we hear that people with insomnia tend to underestimate sleep duration. Up to 50 percent of the time, the electroencephalograms (the graphic records of brain waves produced during overnight sleep studies) of insomnia sufferers reporting insufficient sleep look the same as those of normal sleepers, registering 7 or 8 hours of sleep.

But in people with paradoxical insomnia, the discrepancy between their sleep study results and their subjective assessment of their sleep is huge. The woman whose story appeared in American Family Physician perceived that she was routinely “awake all night.” Yet when she finally went in for an overnight sleep study, the record of her brain waves showed she’d slept a total of 7 hours and 18 minutes. She couldn’t believe it.

A Heavy Burden

You might think, since paradoxical insomniacs are getting a normal amount of sleep, that their insomnia symptoms would be less severe than those of “objective” insomniacs, whose sleep studies show they get less (sometimes considerably less) than 7 or 8 hours. Paradoxical insomnia may sound like “insomnia lite.”

Apparently it isn’t. Research has shown that paradoxical insomniacs tend to be more confused, tense, depressed, and angry than normal sleepers. They also have a higher metabolic rate, which suggests an overall higher level of arousal.

In-depth analyses of brain activity at night attest to this heightened arousal. Compared with objective insomniacs, paradoxical insomniacs experience more high-frequency activity, and less low-frequency activity, in the brain at night. Their sleep is light and vigilant.

Yet it’s often hard for people with paradoxical insomnia to convince others that anything is wrong. When the woman writing in American Family Physician complained about not having slept all night, her husband countered with insistence that she’d slept soundly the whole night. Her friends and colleagues were skeptical too, noting that she had a normal amount of energy and competence at work. She felt increasingly tormented—“not only because of the insomnia,” she wrote, “but also because of a loss of trust from my husband and friends. They said they wondered whether I was pretending just to get sympathy.”

What Could Be Wrong? What Can Be Done?

Scientists can’t explain exactly what the problem is. One hypothesis holds that paradoxical insomnia has something to do with sleep quality, and that treatments that train paradoxical insomniacs to perceive sleep when they’re objectively determined to be asleep may help. (See my other post about paradoxical insomnia here.) But adjusting people’s perceptions may not necessarily resolve all their insomnia symptoms or improve their long-term health.

Other researchers have proposed that paradoxical insomnia occurs due to heightened brain activity during sleep, a condition which is accurately perceived by those who experience it but will require more sophisticated measures to assess scientifically. If it’s true that in paradoxical insomnia the main barrier to satisfying sleep is excessive brain activity and vigilance at night, then therapies designed to lower arousal levels—exercise, yoga, meditation—may help.

How About CBT for Insomnia?

Some experts have expressed doubts about whether CBT for insomnia (CBT-I) has the potential to work as well for paradoxical insomnia as it does for the more common psychophysiologic insomnia. The main value of CBT-I is its ability to help people fall asleep more quickly and decrease nighttime wake-ups. At least when their sleep is assessed objectively, paradoxical insomniacs don’t usually have these particular problems.

But CBT-I also helps to dispel negative beliefs and excessive worry about sleep, which can make any type of insomnia worse. It was an effective insomnia treatment for the woman writing in American Family Physician. “After receiving cognitive behavior therapy,” she wrote, “I began to feel much better and now am able to sleep well most of the time.”

So if it feels like you’re hardly sleeping at all, consult a sleep doctor or a sleep therapist for a proper diagnosis and help in improving your sleep. There may be more insomnia treatment options than you think.

If you feel you’ve benefited from reading this post, please like and share on social media. Thanks!

Posted by Lois Maharg, The Savvy Insomniac

Lois Maharg has worked with language for many years. She taught ESL, coauthored two textbooks, and then became a reporter, writing about health, education, government, Latino affairs, and food. Her lifelong struggle with insomnia and interest in investigative reporting motivated her to write a book, The Savvy Insomniac: A Personal Journey through Science to Better Sleep. She now freelances as an editor and copy writer at On the Mark Editing.

8 Comments

  1. I have suffered from insomnia for nearly 20 years. I have seen psychologists and psychiatrists, read and re-read every CBT-I literature there is, have practiced it as much as I can, yet cannot sleep (sleep initiation is my issue). I spend hours sitting out on my patio, in the dark, staring at stars, relaxing my toenails and clearing my thoughts. I’ll head back to bed and find myself back on the patio, often for hours. CBT-I alone is clearly not working for me, I’ve made it clear that it is not working, yet this is what the sleep doctors keep pushing me toward. I’m absolutely exhausted all day, have little energy in the evening, work and quality time with family is at an all time low because I am so exhausted. Yet at bedtime, I cannot get to sleep. So I go in for yet another sleep study and, of course, all is well. This time I’m told I have paradoxical insomnia. What a slap in the face. For me, I cannot seem to find the shut off switch for my head. I know that racing thoughts are usually a sign of anxiety, but I also believe that racing thoughts and lack of sleep may also be the cause of anxiety. At any rate, I am once again left hanging with the only suggestion from a doctor is to try another 20 years of CBT-I. I don’t dispute that one must have good sleep hygiene, but CBT-I seems pretty non rocket-science to me. There is something else going on, yet nobody seems to know what that is. Unfortunately having an arrogant doctos only exacerbates the problem.

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    1. Hello David,

      I’m sorry to hear about your trouble with insomnia and that your doctors are not receptive to the feedback you’re offering. CBT for insomnia is effective for many people who go through it—70 to 80 percent—but not for everyone. You’re right, it’s not rocket science. If you’re conscientious about following all the rules (which, though they can seem punitive, are not hard to understand) you should start to feel some improvement in your sleep after 2 or 3 weeks, and certainly by the end of one month of treatment. If you don’t, well, then maybe it’s time to look for help elsewhere.

      The first suggestion I have is to find a different sleep doctor, an MD who specializes in sleep medicine (and is a careful diagnostician). Yours may be a situation that requires attention from someone with years of experience in treating sleep disorders of all kinds.

      You mention that sleep initiation is your problem, and I notice your comment came in after 3 in the morning. If you’re usually up that late, have your doctors ruled out the possibility that you have delayed sleep phase disorder? Probably they have. If not, it’s something to check out. Here are a couple blog posts I’ve written about it:

      https://thesavvyinsomniac.com/2016/04/18/insomnia-or-delayed-sleep-phase-disorder/

      https://thesavvyinsomniac.com/2013/06/13/q-a-solutions-for-sleepy-night-owls/

      https://thesavvyinsomniac.com/2015/12/14/qa-should-night-owls-use-sleeping-pills/

      As you’ve probably figured out from some of my other blog posts, I’m an insomniac who was helped by CBT-I. But I would say that of almost equal importance to me in learning how to manage my sleep onset insomnia was daily exercise between 4 and 7 p.m. Vigorous aerobic exercise. I’m told that rigorous weight training can have the same effect.

      These days many physicians shy away from prescribing sleep medication. As a long-term, nightly solution for insomnia it has several drawbacks. Yet it’s possible that a medication could help you. So I encourage you to consult an MD sleep specialist with years of experience treating difficult cases. I too was down on the doctors I consulted for insomnia (mainly GPs) until I started doing research for my book and interviewed some experts at the top of the field. In general I found them to be a very compassionate group. (And I suspect some have skin in the game.)

      Best of luck in finding better solutions than you’ve tried so far.

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      1. I just read your articles. My doctor never even mentioned delayed sleep phase disorder, but quite clearly that’s more likely what I am experiencing. Instead I got “you don’t have sleep apnea, you slept quite well, you need to see a psychologist, and that will be $4,900”. Kind of like having your car not start one morning, you take it in and the mechanic tells you it’s not the battery, then hands you the keys and leave you hanging. Plus charging an arm and a leg.

        As for bright light, I usually wake up, have a quick shower, am out the door and in the sun pretty quickly. I will try Melatonin a bit earlier in the evening. That seems to relax me but still doesn’t shut down the busy-ness in my head. That is part of the issue too. Kind of like an attention disorder. Nothing negative, just can’t seem to ever shut down.

        I do enjoy reading your blogs.

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  2. David, do you have insomnia every night? Mine came up out of the blue last year. I just can’t sleep. Luckily mine only happens once every two weeks now. I just learned to accept it as a fact of life. I’m just scared it may start to become more frequent. Also, what I hate even more than the occasional insomnia at night is that I have completely lost the ability to nap in the daytime. So when I get hit by a bad night, I’ll feel terrible the following day until nighttime comes again. I agree, there is something going on inside that science has not really uncovered yet.

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    1. Thank you both. Yes, it is every night, and like you, I have no ability to nap in the day (or in the evening for that matter). It’s just frustrating because everyone in the medical community seems pretty confident it’s a psychological issue, yet this hasn’t been resolved in 20 years and I’m fairly decent about sleep hygiene (aside from the other night when I stumbled onto this website… but seriously, the computer and TV are usually off). Well, now it is a psychological issue because I am losing focus at work, at home, and no longer have any desire to do much of anything. I can’t say I’ve engaged in a vigorous workout but do stay active on my job (desk job but do need to move about quite often).

      I guess my recent frustration is due to my recent sleep study in which everything was fine. Yet I recall lying there for hours. They told me I was sleeping within 10 minutes, and I know that wasn’t so. So they tell me it’s paradoxical insomnia, but only after pushing for further explanation. My wife will attest that I am up all night, frequently getting up to sit at the back patio in the middle of the night, sometimes for hours. Yet that doctor just refers me back to CBT-I. Just hearing others have similar issues lets me know there is more to it. Yet. because science hasn’t discovered it, it doesn’t exist. I just need to find a great sleep doc but not sure where to begin as my options seem to be exhausted where I live as none seem to specialize in sleep medicine first (many are psych docs first with sleep medicine as a side).

      I hope yours doesn’t turn into anything more frequent. Best of luck.

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      1. Hi David,

        In light of the information you shared yesterday, that you had a sleep study and, based on that, the doctors told you that you sleep quite well, their diagnosis of paradoxical insomnia sounds appropriate. However, while I can see why they suggested that you see a psychologist, maybe a bit more information about paradoxical insomnia would help. I will share what I know.

        Scientists have been trying to understand why people with insomnia have such varied symptoms for a long, long time. Some insomniacs go in for a sleep study and their estimate of how long they sleep is quite accurate. They estimate 5.5 hours, and polysomnography (PSG) indicates that they slept a 5.5-hour night. Others estimate that they sleep 1 or 2 hours but PSG indicates they slept 7 or 8 hours a night. For a while now, some experts have referred to the former example as “objective” insomnia and the latter, “subjective,” or paradoxical, insomnia and treated them as different insomnia types. Objective insomniacs are often diagnosed with psychophysiologic insomnia. CBT for insomnia is known to work quite well for them, so it is recommended as the first line of treatment.

        But to my knowledge, there is no standard protocol for the treatment of paradoxical insomnia. As it did for the woman whose testimonial I wrote about in this blog post, CBT for insomnia may work for some people (which is probably why your doctors recommended that you see a psychologist). It may not work so well for others. I mentioned other types of treatments therapists have tried for people with paradoxical insomnia in the first post I wrote about it, which I’ve referenced in this post.

        But to regard the problem in paradoxical insomnia as “psychological” is an oversimplification at best. I spend quite a bit of time developing this topic in my book, The Savvy Insomniac, but following is the gist. It used to be that scientists thought of sleep and waking as whole-brain states. You were either asleep or awake, and there was nothing in between.

        Now studies of animals and humans have found that in some cases this is not an accurate reflection of what actually goes on inside the brain. Neuroimaging studies conducted on humans have shown that it is possible for most of the brain to be sleeping while a few key areas of the brain are behaving as though they are still awake. These areas may be taking in information from the environment—and possibly even processing it—while the rest of the brain is asleep. This explanation for what goes on in paradoxical insomnia suggests that, while there may be a psychological component, it is mainly a physiological problem. The solution lies in shutting down activity in those few rogue areas of the brain that insist on remaining in a wakeful state!

        I wish science were further along in identifying effective treatments for paradoxical insomnia. Part of the solution may consist of learning to perceive PSG-identified sleep. To that end, Michael Schwartz has developed a very inexpensive app for smart phones that trains people to recognize when they fall asleep. It’s the subject of a recent scientific study that found it was quite accurate in recognizing stage 2 (an early stage of) sleep. I’m going to write another blog post about it soon.

        Here’s the URL of an older blog post about it: https://thesavvyinsomniac.com/2016/09/28/sleep-tracking-no-now-its-sleep-training/

        And here’s Michael’s Sleep on Cue website: http://www.sleeponq.com/ . I can’t assure you that it will help. But it might.

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  3. Hi David!

    How many hours did they give you for your sleep window? Maybe you need to go down to four. I only saw a shift when my sleep window went to four hours instead of the recommended five.

    I wish you the best!

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    1. Awww, four? I guess I feel lucky my worst nights are five hours. I normally sleep 7-8 hours now.

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