It can be hard to tell whether you are awake or asleep, particularly for people with insomnia. This is called paradoxical insomnia or sleep state misperception. 

You may feel like you are awake all night, but you may be sleeping for hours. Your partner may notice that you slept soundly, but you feel that you were up until all hours. Are you paradoxically not sleepy despite barely sleeping at night?

What is Paradoxical Insomnia?

Paradoxical insomnia is where people feel that they are barely sleeping despite the fact that when sleep is measured objectively such as during a sleep study or with a wearable device they are sleeping much more than they think. People with paradoxical insomnia and not normally sleepy during the day, which is part of the paradox. Not being sleepy despite thinking they haven’t slept.  Whilst paradoxical insomnia and feeling there is no sleep at all can affect about 5% of people with insomnia, it is actually very common for people with insomnia to under-estimate how much sleep they are getting. 

Previously known as sleep state misperception or subjective insomnia, paradoxical insomnia can be problematic to assess and treat. It can be very distressing if people in your life don’t believe you have insomnia. However, you don’t need to worry too much since it can be treated.

How can we be asleep yet feel awake?

Deeper sleep, where we are less aware of things, usually occurs more at night. An exception to this is people with insomnia, who often feel they sleep their best just before it’s time to get up in the morning.

Patients with insomnia, particularly those who under-estimate how much sleep they are getting, need longer continuous sleep bouts to perceive sleep onset. This has been shown in research conducted and published by Dr Lieke Hermans showing people with insomnia needed over 30  minutes of undisturbed sleep to register that they had been asleep. Dr Hermans’ research also gave rise to the Sleep Fragment Perception Index, providing a useful measure to characterize sleep state misperception.

You can listen to an interview with Dr Hermans in this episode of the Sleep Talk podcast.

How can you measure how much sleep you are getting?

Most adults require between seven and nine hours of nightly sleep. Children and teenagers need substantially more sleep, particularly if they are younger than five years of age.

There are many ways to figure out how many hours of sleep you are getting. The easiest method is for you to ask your partner to monitor it. Often a partner will give examples of when you have been asleep but thought you had been awake.

You can record yourself using a smartphone app such as ‘Snorelab‘. If you think you have been awake but replay audio from parts of the night and can hear yourself snoring or breathing steadily, that may help indicate you have been asleep.

Wearables such as FitBit or smartwatches with a sleep tracking feature can also be helpful but do tend to underestimate sleep in people with insomnia.

What should you do?

Managing sleep state misperception with sedating medications to make it feel like you have been asleep can be harmful as this is often a situation where I find people exceeding the recommended dose or combining multiple medications including alcohol.

It is important not to overuse medication to try to induce a state of unawareness during sleep. It is common when people use high doses of medication yet still feel that they aren’t sleeping to find that they are actually sleeping and just giving themselves more side effects by taking more and more medication.

If you are concerned that you are not sleeping despite following good sleep hygiene measures and cognitive behaviour therapy for insomnia or have tried medication and didn’t respond as you expected, talk to your health professional. This is a common situation where you could be referred to a sleep specialist for assessment and to measure sleep and discuss treatment options. Talking this through with a professional experienced in managing sleep problems can be helpful and was shown in a pilot study to improve symptoms. 

Related links and posts:

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