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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When 7-Hour Nights Aren’t Good Enough

To many insomnia sufferers, the prospect of sleeping 7 hours a night sounds great. Insomniacs who write to me with news that they’ve achieved this feat after undergoing some type of insomnia treatment are thrilled.

Other people are not so thrilled about 7-hour nights. No matter how long they sleep, they wake up feeling unrested. Insufficiently refreshing sleep is the main symptom of people diagnosed with nonrestorative sleep.

Nonrestorative sleep may or may not be a form of insomniaTo many insomnia sufferers, the prospect of sleeping 7 hours a night sounds great. Insomniacs who write to me with news that they’ve achieved this feat after undergoing some type of insomnia treatment are thrilled.

Other people are not so thrilled about 7-hour nights. No matter how long they sleep, they wake up feeling unrested. Insufficiently refreshing sleep is the main symptom of people diagnosed with nonrestorative sleep.

A Closer Look at What Nonrestorative Sleep (NRS) Feels Like

Jeremy wrote to me recently complaining of insomnia. But the way he described his problem was different from the insomnia stories I usually hear:

I do not struggle with sleep onset at all or awakening from sleep. But the ‘sleep’ I do receive is of such low quality it feels like I did not sleep at all. . . . I am often unconscious for 6 to 7 hours. But it feels like I receive practically nothing (the most similar feeling I have ever experienced is being extremely hung over from excessive alcohol consumption).

To “receive practically nothing” after a full night’s sleep makes Jeremy’s situation sound rather desperate. Normal sleep affords many benefits: it allows for the conservation of energy, enables the growth and repair of body tissue, shores up important memories and prunes the unimportant ones, enables the processing of emotion, improves our ability to perform tasks and procedures. Importantly, a night of sound sleep primes us to meet the demands of the day ahead. If Jeremy’s waking up feeling unrested, then even though he’s sleeping, he’s really missing out.

A Subjective Diagnosis

The causes of NRS are still unknown and no objective tests for it exist. Identifying its biological markers is a project only just begun. So the diagnosis of NRS is subjective, based on symptoms alone.

In 2013 Canadian investigators published an NRS questionnaire after identifying 4 key features of the disorder. Compared with healthy sleepers, people with NRS tend to:

  1. Experience poor quality sleep and wake up feeling unrested
  2. Have more aches, pains, and medical problems, including symptoms of panic
  3. Experience impaired daytime functioning (e.g., experience low energy and alertness, and have trouble with memory and concentration)
  4. More often feel depressed and/or irritable during the day

Is It Insomnia or Not?

Sleep experts have tossed this question around for years. The daytime symptoms of NRS are similar to those associated with insomnia (although the impairment caused by NRS may actually be more severe). Also, overnight sleep studies of people with NRS often look the same as those of normal sleepers, suggesting that NRS might have something in common with paradoxical insomnia, a diagnosis often given to people whose sleep studies look normal but who feel like they’re only getting an hour or two of sleep a night.

But the differences between NRS and insomnia may prove to be more important and argue for NRS to be considered a separate sleep disorder. Unlike people with insomnia, who report trouble falling asleep or staying asleep, many people with NRS experience neither of these nighttime problems.

Funded by a grant from the National Institute of Mental Health, a team of researchers looked for differences between the symptoms of insomniacs and people with NRS in large sample of the general population. They noted the following:

  • The prevalence of insomnia increased with age; the prevalence of NRS decreased with age.
  • Insomnia was significantly associated with cardiovascular disease; NRS was not associated with CVD but was significantly associated with different medical problems, including emphysema, chronic bronchitis, habitual snoring, sleep apnea, and restless legs syndrome.
  • After adjusting for confounding factors, levels of C-reactive protein, a marker of inflammation, were significantly high in people with NRS only but not in people with insomnia only.

The elevated levels of C-reactive protein might be clue about the causes of NRS. “Indeed,” the authors write, “NRS is a core symptom of chronic fatigue syndrome and some forms of major depression, both of which have been shown to be associated with increased . . . inflammatory markers.” For anything more definitive, we’ll have to wait and see.

How Is NRS Treated?

The medical literature is sadly lacking here. If you think you might have NRS, consult a sleep specialist and see what he or she recommends. NRS often occurs in conjunction with another medical problem, such as fibromyalgia or sleep apnea, or a psychiatric problem such as depression. Treatment of that problem may improve sleep quality and help to resolve the issue with NRS.

Some research has also shown that the sleep of people with NRS is characterized by increased alpha wave activity, a phenomenon associated with hypervigilance. If this is true, then vigorous daily exercise may help.

Sleep Studies: Do You Really Need One?

If you haven’t had a sleep study, you may wonder if spending the night at a sleep clinic might help the doctor understand your problem and how to fix it. Polysomnography, or PSG, is the test conducted at the clinic. New guidelines from the American Board of Internal Medicine (ABIM) clarify when PSG is useful in cases of chronic insomnia and when it isn’t. Here’s a summary and explanation of the guidelines.

Sleep studies are useful when insomnia is complicated by another disorderWhen I ask people with persistent insomnia if they’ve had a sleep study, the common responses I get are these:

  • “I had one and all I learned from it was that I don’t have sleep apnea.”
  • “I want one, but my doctor won’t write the prescription.”

If you haven’t had a sleep study, you may wonder if spending the night at a sleep clinic might help the doctor understand your problem and how to fix it. Polysomnography, or PSG, is the test conducted at the clinic. New guidelines from the American Board of Internal Medicine (ABIM) clarify when PSG is useful in cases of chronic insomnia and when it isn’t. Here’s a summary and explanation of the guidelines.

When a Sleep Study Is in Order

PSG is good at detecting sleep apnea, sleep-related movement disorders, and violent or harmful behavior that might be occurring at night. If a doctor suspects that your insomnia is associated with any of these disorders, you’ll likely be going in for a sleep study.

Occasionally a person with insomnia reports such an unusual assortment of symptoms that, even after taking an extensive patient history, the doctor can’t figure out what’s going on. Here, too, PSG may help. The doctor may also prescribe a sleep study if you’ve undergone treatment for insomnia (with or without drugs) but your sleep has failed to improve.

When Sleep Studies Won’t Help

But neither the ABIM nor the American Academy of Sleep Medicine recommends sleep studies for other insomnia patients. Here are some of the reasons.

1.  PSG cannot do much except confirm the symptoms you report to the doctor during a clinical interview.

  • Let’s say you wake up several times at night and have trouble falling back to sleep. PSG may confirm that you experience these wake-ups but will not shed light on why.
  • Or maybe your problem is that it usually takes you a long time to fall asleep. Upwards of $2,000 is a lot to spend on a procedure that merely corroborates what you already know.

2.  PSG does a poor job of discriminating between normal sleepers and people with insomnia. In fact, up to 50 percent of the time, the brain activity of insomniacs looks identical to that of normal sleepers.

3.  In some insomniacs, there is abnormal brain activity occurring at night—activity typically associated with being awake. But standard PSG will not show evidence of this wake-like activity. As a measure of what’s going on in the brain at night, PSG is not finely tuned.

4.  Finally and importantly, in most cases of persistent insomnia, PSG will not suggest a course of treatment that differs from treatment that would be prescribed based on a thorough clinical interview.

  • If your complaint is that you’re a light sleeper and wake up frequently at night, the doctor will probably prescribe cognitive-behavioral therapy for insomnia (CBT-I) or some other behavioral treatment before considering medication. PSG might corroborate your symptoms but would not alter the diagnosis or the treatment.
  • Or let’s say your main complaint is that your thoughts keep you too wound up at night to fall asleep easily. The doctor isn’t going to need for you to undergo a sleep study in order to diagnose and treat the problem.

The Bottom Line

Sleep studies are an indispensable tool for people suspected of having sleep apnea and many other sleep disorders. But as conducted now, they’re of no help to insomnia sufferers unless your insomnia is related to another health problem.

If you’ve had a sleep study, what did you learn from it?