Paradoxical 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!