Paradoxical Insomnia: A Second Look at Treatments

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.

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.

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Are Insomniacs Unreliable at Assessing Sleep?

You’ve heard it said before: insomniacs typically overestimate how long it takes to fall asleep and underestimate the amount of sleep we get. Time and again, sleep experts ask us to estimate our sleep time. Then they conduct overnight sleep studies with polysomnography (PSG) and find, on average, that we fall asleep faster and sleep longer than we think.

Are insomniacs just unreliable when it comes to estimating time? What else might account for this discrepancy? Should we be reassured that we’re probably sleeping more than we think?

Insomnia sufferers underestimate how long they sleepYou’ve heard it said before: insomniacs typically overestimate how long it takes to fall asleep and underestimate the amount of sleep we get. Time and again, sleep experts ask us to estimate our sleep time. Then they conduct overnight sleep studies with polysomnography (PSG) and find, on average, that we fall asleep faster and sleep longer than we think.

Are insomniacs just unreliable when it comes to estimating time? What else might account for this discrepancy? Should we be reassured that we’re probably sleeping more than we think?

Time Estimates in the Daytime

Normal sleepers are fairly accurate when it comes to assessing their sleep. Their estimates of sleep onset latency (the time it takes to fall asleep) and total sleep time are in sync with the results of PSG.

Overall normal sleepers are also quite accurate at estimating time during the day. They can reliably estimate various time intervals (5 seconds, 35 seconds, 19 minutes) and keep a steady beat in a finger tapping task.

So can insomnia sufferers. Research suggests that overall, we, too, are quite accurate at estimating time intervals and keeping a steady beat during the daytime. It’s not the perception of time per se that gets distorted in insomnia. Insomniacs’ unreliability in estimating the passage of time occurs only at the night.

“It Takes Me Over an Hour to Fall Asleep”

Most studies show that people with chronic insomnia tend to overestimate sleep onset latency. For example, after having a sleep study, you’re told you drifted off 25 minutes after closing your eyes but you could swear it took you at least twice as long to nod off. How to account for this discrepancy?

One thing to keep in mind is that Stage 1 sleep—the lightest sleep stage, when the faster, unsynchronized brain waves associated with wakefulness are slowing down into more synchronized alpha and theta rhythms—is easy to perceive as wakefulness. In fact, if you’re woken up during Stage 1 sleep, you may feel you were never sleeping at all.

Research has also shown that unlike good sleepers, insomniacs tend to have elevated levels of high-frequency brain activity in the period leading up to sleep. These faster brain waves are associated with pre-sleep cognitive arousal—with thinking, rumination, and worry. They’re also associated with low-level awareness of what’s going on in the environment—a flushing toilet, a flash of lightening, the smell of skunk wafting through the window.

Unsurprisingly, insomniacs have been shown to take twice as long as normal sleepers to descend into deep sleep. So we’re hovering longer in the lighter sleep stages. All these things could help explain why we perceive we’re taking longer to fall asleep than PSG says we are.

“I Don’t Get Much Sleep”

Not all insomniacs are created equal. When it comes to estimating total sleep time, some insomnia sufferers are relatively good at it. (And results of some studies suggest that some insomniacs actually overestimate their total sleep time.) These are the so-called objective insomniacs, whose estimates of sleep time match up pretty well with their assessments by PSG. The diagnosis for this type of insomnia is often psychophysiological insomnia.

People whose sleep studies indicate they’re consistently sleeping less than 5 hours a night are called “short sleepers.” Short sleep is associated with physiological hyperarousal and an elevated risk for related medical disorders, as well as persistent trouble sleeping. Of all the variants of insomnia, short sleep is thought to be the most severe.

All I Get Is 1 or 2 Hours”

Other insomniacs’ perceptions of sleep duration are wildly at odds with assessment by PSG. A person who complains of getting just 1 or 2 hours’ sleep a night and goes in for a sleep study is often found to be sleeping 6, 7, or even 8 hours a night. The diagnosis in this situation is paradoxical insomnia, a disorder affecting about 26 percent of people with chronic insomnia.

Because their sleep duration is normal and their sleep architecture (as assessed by PSG) largely intact, the thinking is that these insomniacs are getting most of the benefits that sound, sufficient sleep affords. This may be reassuring. But the jury’s still out on the underlying mechanisms at play. Multiple irregularities may contribute to the feeling of being awake when most of the brain is asleep.

The Upshot

Should we be relieved to know that most of us are getting at least a little more sleep than we think? It’s not a bad idea. Once I stopped caring about how much I was sleeping, my sleep improved. Whether or not this would be borne out in a sleep study, it feels like I fall asleep faster and sleep longer than I did before.

If you can swallow the idea that in this one place your perceptions might be a tad unreliable (believe me, I know how hard this can be!), you won’t regret it.

Q&A: Start Sleep Restriction Right for Best Results

“I’m on Day 4 of SRT and it isn’t going well,” Jenny wrote recently. “I finally had an appointment with a sleep therapist last week. He talked to me about SRT and gave me a 7-hour sleep window, from 11 p.m. to 6 a.m. My usual bedtime is 9:30 so I had some apprehensions. But I started 4 days ago.

“Since then I haven’t slept more than 3 hours a night. It’s really hard for me to stay up till 11, and then when I get in bed I’m wide awake! In the morning I’m so tired I can hardly keep my eyes open! Is this normal? I’m afraid I may be a treatment failure. Any advice?”

Before sleep restriction, keep a sleep diary for a week to ensure successRecently I’ve heard from a handful of people starting out with sleep restriction therapy (SRT), a treatment for insomnia. All were in a similar predicament. Here’s what Jenny wrote:

 

 

 

 

 

 

I’m on Day 4 of SRT and it isn’t going well. I finally had an appointment with a sleep therapist last week. He talked to me about SRT and gave me a 7-hour sleep window, from 11 p.m. to 6 a.m. My usual bedtime is 9:30 so I had some apprehensions. But I started 4 days ago.

Since then I haven’t slept more than 3 hours a night. It’s really hard for me to stay up till 11, and then when I get in bed I’m wide awake! In the morning I’m so tired I can hardly keep my eyes open! Is this normal? I’m afraid I may be a treatment failure. Any advice?

First Few Weeks of Treatment

The first few weeks of SRT are not much fun. Your time in bed is cut short at night and naps are not allowed. It can be hard to figure out what to do during the extra hours you’re up. In the daytime you may feel sleep deprived: exhausted, cranky, off your game.

Is this normal?

Research suggests it’s not abnormal. Results of a study of 16 insomniacs in the UK showed that while their sleep was greatly improved following SRT, during the first few weeks of treatment, they were sleep deprived. Like Jane Fonda said: no pain, no gain!

The Week Before Restriction Begins

Jenny’s experience of the first few days of SRT is not so unusual. But nowhere in her email—or in the others I received—was there any mention of having kept a sleep diary* during the week before treatment. Also, all 4 I heard from were starting SRT with rather generous sleep windows: 6.5, 7, and even 8 hours in bed. Yet they didn’t say how those sleep windows were established.

Maybe sleep diaries were kept—and the writers just didn’t mention them. Or maybe a therapist determined, based on a clinical interview, that starting out with a generous sleep window was the best way to treat insomnia in that particular person. (See my blog on paradoxical insomnia for more on this.)

But I suspect that at least some who wrote had plunged right in to sleep restriction without filling out a sleep diary the week before and that their sleep windows were set arbitrarily. This can make the first week of sleep restriction even rockier than it needs to be—and might lead people to think the treatment is failing and quit.

How Much Do You Sleep?

To set your sleep window (time allowed in bed) at the start of SRT, you need to know how much sleep you’re getting from night to night. Maybe you have a pretty good idea of that already. In reality, though, most insomnia sufferers are not very good at estimating sleep duration.

Keeping a sleep diary during the week before treatment won’t necessarily make your estimate more accurate—but it might. By noting in the diary how many times you wake up each night, how long the wake-ups last, and the variability in your sleep from night to night, you might get a more realistic read on the average number of hours you sleep.

Look Before You Leap

Regardless of whether keeping the diary clues you in to anything you didn’t already know, the results are an indication of how much your time in bed should be restricted at the start of sleep restriction:

  • You discover you’re a 6-hour sleeper? Start SRT with a 6-hour sleep window.
  • You’re sleeping 5 hours 15 minutes a night? Start with a 5.25-hour sleep window.
  • There’s one exception: most sleep experts (but not all) recommend starting SRT with nothing less than a 5-hour sleep window. So 4-hour sleepers are usually advised to start with a 5-hour window.

If you start with a too-small sleep window, you’ll wind up very sleep deprived. But if your sleep window is too generous (as I suspect may have been the case for Jenny and the others who wrote in), you’re likely to continue with the same broken sleep pattern you’ve known from before. This could sour you on sleep restriction even before you’re off the ground.

So keep a sleep diary for a week before starting SRT and set your sleep window accordingly. It’s the quickest path to success.

* Download this sleep diary from the National Sleep Foundation and make several copies for use during SRT.

What was your experience like during the first week of sleep restriction therapy?

Paradoxical Insomnia: What It Is & How It’s Treated

Do you normally get just an hour or two of sleep? Are there nights when you don’t sleep at all?

You may have paradoxical insomnia. Despite its prevalence, the whys and wherefores remain largely unknown. But researchers have made a little headway in recent years, and here’s what they say now.

people with paradoxical insomnia report 1-2 hours of sleep but a sleep study isn't in agreementDo you normally get just an hour or two of sleep? Are there nights when you don’t sleep at all?

You may have paradoxical insomnia. An overnight sleep study would confirm the diagnosis. Despite your perception of getting very little sleep, your electroencephalogram (EEG)—the graphic record of your brain waves produced during an overnight sleep study—would indicate that you were actually sleeping a 6.5- to 8-hour night.

This sleep disorder seems to be fairly common. About 9 to 40 percent of the people diagnosed with insomnia are estimated to have it. Despite its prevalence, the whys and wherefores remain largely unknown. But researchers have made a little headway in recent years, and here’s what they say now.

Is There Really Anything Wrong?

Formerly called pseudoinsomnia and more recently sleep state misperception, the sleep of people with paradoxical insomnia looks similar to normal sleep in a conventional sleep study. In fact, the EEG of a person with paradoxical insomnia can look identical to the EEG of a normal sleeper. Doctors used to tell their patients that nothing was wrong.

But people with paradoxical insomnia do have grounds for complaint, and scientists are now a little closer to understanding why. In a 1997 study, Michael Bonnet and Donna Arand reported that compared with normal sleepers, people with paradoxical insomnia (1) were more confused, tense, depressed, and angry, and (2) had a significantly increased 24-hour metabolic rate. This is suggestive of hyperarousal, a characteristic of people with insomnia.

Subjective vs. Objective Insomnia

Paradoxical insomnia, also called subjective insomnia, differs from objective insomnia—the type that’s more familiar. Compared with paradoxical insomniacs, objective insomniacs

  • sleep significantly fewer hours, as recorded on the EEG
  • tend to be less inaccurate at estimating total sleep time
  • may have psychological and physiological symptoms that are more severe.

In a 2002 study, Andrew Krystal and colleagues presented an in-depth analysis of brain wave patterns that shed light on more differences. Compared with objective insomniacs, paradoxical insomniacs

  • had less delta wave activity during sleep (delta waves are the predominant waveform in deep sleep, the restorative stuff). The lower the delta activity, the greater the discrepancy between the total sleep time recorded on the EEG and the sleep time estimated by the patient.
  • experienced more alpha, beta, and sigma wave activity during sleep—brain waves commonly associated with arousal, perception, and thinking. This suggests that people with paradoxical insomnia are prone to perceiving and possibly even processing information when they sleep.

Overall, then, the sleep of people with paradoxical insomnia tends to be light and characterized by hypervigilance. Scientists are not sure if this sleep disorder is simply a way station en route to objective insomnia or a completely different kettle of fish.

Treatment of Paradoxical Insomnia

There is no standard treatment for people with paradoxical insomnia. Drug-free behavioral therapies such as sleep restriction and stimulus control may not help.

If physiological hyperarousal is the main problem for insomniacs in this group, one way to address it would be through physical training. Daily aerobic exercise—and possibly the daily practice of yoga, tai chi, or qi gong—would cut down on arousal and likely promote sounder sleep.

On the other hand, a team of Italian researchers thinks the problem is mainly perceptual. These patients “may have a sort of agnosia [a partial or total inability to recognize something by use of the senses] of their sleep,” they conclude.

Investigators at The University of Alabama treated four paradoxical insomnia patients with a kind of “sleep education.” After behavioral therapies failed to help, a specialist talked to each patient about sleep and sleep staging. Together, they looked at the patient’s EEG, watched a video of the patient sleeping, and noted differences between the recording of sleep and patient perceptions. After receiving the information, 2 of the 4 patients reported falling asleep much more quickly and sleeping a lot longer.

Ralph Downey, a sleep specialist at Loma Linda Sleep Center, conducts therapy sessions for people with paradoxical insomnia in a sleep lab. Each time a patient falls asleep, she’s awakened and asked whether she thinks she’s asleep or awake. After repeated awakenings, the patient develops the ability to recognize the bodily cues that accompany sleep. Her perception of sleep becomes much closer to that recorded on her EEG.

Michael Schwartz, whose SleepQ app I reviewed last fall, believes that the same thing can be accomplished with a smart phone and an app costing just $4.99.

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