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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Lifelong Insomnia? Don’t Give Up on It Yet

Have you had insomnia all your life? Have your parents said you were a poor sleeper even as a baby?

Trouble sleeping that starts early in life is called idiopathic insomnia. If insomnia is still the black box of sleep disorders, then idiopathic insomnia is the little black box inside the black box.

Here’s what is known about the disorder and options for management.

Lifelong insomnia can be treated by sleep specialist or therapistHave you had insomnia all your life? Have your parents said you were a poor sleeper even as a baby?

Trouble sleeping that starts early in life is called idiopathic insomnia. If insomnia is still the black box of sleep disorders, then idiopathic insomnia is the little black box inside the black box.

Here’s what is known about the disorder and options for management.

What Is Idiopathic Insomnia?

Idiopathic insomnia begins in childhood, sometimes at or soon after birth. Trouble falling or staying asleep or reduced sleep duration is pretty much a nightly affair regardless of situational changes. The disorder is uncommon, affecting less than 1% of the population.

There is no identifiable cause. The presumption is that idiopathic insomnia is driven mainly by biological factors, and at least some of them are probably inherited. Abnormalities in the circadian system or the homeostatic process may be involved and/or there may be a problem in the circuitry controlling sleep and waking in the brain.

A Chronic Sleep Disorder, but How Well Defined?

Idiopathic insomnia is a chronic sleep disorder with familiar insomnia symptoms:

  • Trouble falling or staying asleep, or sleeping long enough, for more than 3 months despite adequate sleep opportunity
  • Daytime distress and impairment, including reduced stamina, low mood, and trouble thinking and learning

Research on the defining features of idiopathic insomnia is mixed. On one hand are a few studies showing significant differences between people with idiopathic insomnia (IdI) and those with psychophysiological insomnia (PI), the garden-variety insomnia that typically develops later in adolescence or adulthood. PI is often triggered by a stressful event; situational factors do not figure in IdI. PI is said to persist mainly due to psychological and behavioral factors that develop in response to poor sleep: conditioned arousal in bed, poor sleep hygiene (going to bed early to catch up on sleep, for example), and anxiety about sleep. Psychological factors are less typical in IdI.

On the other hand is research showing no major differences between PI and IdI when assessed by polysomnography (the overnight test in the sleep lab) or by self-report of psychological symptoms. Research suggests that arousal levels are higher among people with IdI than in people with other kinds of insomnia, though, leading some sleep experts to speculate that IdI is simply a more severe manifestation of PI.

What Can Be Done?

Without scientific certainty about the causes of IdI or whether the disorder is distinct from other kinds of insomnia, IdI is best treated on a case-by-case basis by a sleep specialist. Following are options for treatment.

Especially if a person with IdI has misconceptions and/or anxiety about sleep,

  • Cognitive behavioral therapy for insomnia (CBT-I) may help. CBT-I typically consists of two behavioral components—stimulus control therapy and sleep restriction therapy—and a cognitive component designed to decrease psychological barriers to sleep. Sometimes just changing your attitude about sleep can bring about demonstrable sleep improvements.
  • Acceptance and commitment therapy (ACT) may help. ACT focuses on building mindfulness skills so that, rather than trying to suppress, manage, and control emotional experiences, people develop psychological flexibility and learn to behave in ways that reflect their values and increase well-being. This approach, too, can change the way you feel about sleep and in the process improve your sleep.

If round-the-clock hyperarousal is driving IdI, then therapies designed to decrease arousal may help.

  • Regular, moderate-to-vigorous exercise—activities such as aerobics, calisthenics, biking, running, and weight-lifting—has been shown in recent studies to increase total sleep time and decrease levels of cortisol (a stress hormone).
  • Yoga, too, has been shown to decrease feelings of arousal and promote stress tolerance.

Medication for Idiopathic Insomnia

The issue of sleeping pills for chronic insomnia is increasingly fraught. Many drugs approved for the treatment of insomnia, taken nightly over time, may degrade sleep quality and result in alarming side effects, especially in older adults.

That said, while the medication prescribed for IDI is usually a benzodiazepine or a Z-drug such as zolpidem or eszopiclone, a second pharmacological approach, according to a paper by Michael Perlis and Philip Gehrman, involves use of a melatonin agonist such as ramelteon (Rozerem). No studies of the effects of this sleeping pill on the sleep of adults with IdI have been conducted. But in two studies of children aged 6 to 12 years with chronic idiopathic childhood sleep-onset insomnia, melatonin put them to sleep significantly sooner—by 1 hour.

If you’re contemplating managing lifelong insomnia with drugs, get some professional advice. This is one place where you really need the help of a specialist knowledgeable in the medical treatment of chronic insomnia.

At what age did your trouble sleeping start? What kinds of treatments—if any—have helped?

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.