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What Is Sleep State Misperception?

Medically Reviewed by Neha Pathak, MD on July 15, 2021

Sleep state misperception is a condition where you underestimate how much you’ve slept the night before. You may feel like you were awake all night, but you actually slept for hours.

It’s also called paradoxical insomnia or subjective insomnia. You think you can’t sleep well, but there’s no evidence of it on sleep tests. Your partner may notice that you slept soundly, but you feel that you were up until all hours. You function well during the day with no signs of fatigue that often come with insomnia.

Paradoxical insomnia may affect only about 5% of people with insomnia. This condition can be very distressing if people in your life don’t believe you really have insomnia. But it can be treated effectively.

Potential Causes of Sleep State Misperception

It’s unclear what causes paradoxical insomnia. You may be over-aroused or hyperaware during sleep. Your perception of time, or how long you slept, might be out of balance.

It’s possible that sleep state misperception may be related to your mental health or mood. Before bedtime, you may worry or think about the stress in your life, causing you to misjudge how long or soundly you slept. People with sleep state misperception can also have depression, anxiety, or chronic stress. If you can’t find effective ways to overcome or manage your stress, it may trigger sleep state misperception.

Some research suggests that this condition may have physical causes, too. During sleep, your metabolism or oxygen levels in your body may be increased. Your metabolic rate is how much energy your body uses. Your metabolic rate may be higher in sleep state misperception, but lower than in insomnia. This may mean sleep state misperception is a milder version of insomnia, or even a condition that happens before you get insomnia.

How Is Sleep State Misperception Diagnosed?

Your doctor can diagnose sleep state misperception based on your symptoms. They can also refer you to a sleep specialist, who can perform a sleep study, also called polysomnography. This study includes tests to measure the amount of time you slept, your breathing, heart rate, oxygen levels in your blood, and body movements during sleep. They may use an electroencephalogram (EEG) test to measure your brain activity during sleep using sensors attached to your scalp.

Polysomnography can measure how long and how well you sleep. If the results don’t match how you think you slept, it’s a sign of a sleep state misperception.

To be diagnosed with sleep state misperception, you must:

  • Sleep a total of 6.5 hours or longer on average
  • Have a sleep efficiency rating of 85% or greater
  • Have less impaired daytime function than you would have based on how long you believe you sleep on average
  • Feeling that you’ve had insomnia for at least 1 month
  • Mismatch between your perceived lack of sleep and your polysomnography test results

Sleep diary: Use a diary or journal to keep track of how long or well you sleep. You can share your sleep diary with your doctor to see how your perception of your sleep matches up with the results of your sleep tests.

Can This Condition Harm You or Your Relationships?

Even though you’re sleeping more than you think, paradoxical insomnia could cause you some harm. You’re likely to have distress about your condition, and may feel angry, tense, confused, or upset.

You may have conflicts with your family, friends, or co-workers because you feel that you have insomnia, but they don’t see any signs of a problem. You may begin to feel that you don’t trust each other. They may accuse you of making up a health condition because you want attention. They become tired of talking about a health problem that they don’t believe you really have.

Sleep state misperception could also be harmful if you self-treat your condition with sleep medicines like diphenhydramine (Sominex, Nytol, Unisom) or doxylamine succinate (Unisom SleepTabs). These are OTC antihistamines that make you drowsy. While it’s safe to use sleep aids occasionally, you can build up tolerance to them. Over time, these drugs won’t work as well for you. They can also cause you to have confusion, dry mouth, dizziness, or drowsiness during the daytime.

How Is Sleep State Misperception Treated?

While there’s no standard treatment for sleep state misperception, your doctor or sleep specialist can prescribe cognitive behavioral therapy for insomnia (CBT-I). This is a comprehensive sleep therapy that can include:

  • Sleep hygiene education: learning about habits that help you get good sleep, like exercising regularly, reducing noise in your bedroom, having a sleep schedule, and cutting back on caffeine
  • Stimulus control: routines that signal to your body that your bed is for sleeping, like setting a regular bedtime and rise time, going to bed only when you’re sleepy, getting out of bed when you can’t fall asleep or go back to sleep, and making your afternoon naps only 10-15 minutes
  • Progressive muscle relaxation: before bedtime, alternate tightening and relaxing muscle groups to relax yourself and go to sleep

CBT-I may help reduce your anxiety and worry about your sleep quality. It can help relieve sleep state misperception, so you gain a more accurate sense of how long and well you sleep. You may feel more confident about being able to get quality sleep. This can even help improve strained relationships with family and friends.

WebMD Medical Reference

Sources

SOURCES:

Psychosomatic Medicine: “Sleep Misperception and Chronic Insomnia in the General Population: The Role of Objective Sleep Duration and Psychological Profiles,” “Physiological Activation in Patients With Sleep State Misperception.”

American Family Physician: “Paradoxical Insomnia: Misperception of Sleep Can Be a Tormenting Experience.”

Neurotherapeutics: “Classification of Sleep Disorders.”

Behavioral Sleep Medicine: “Sleep Education for Paradoxical Insomnia.”

National Health Service: “How Can I Speed Up My Metabolism?”

Mayo Clinic: “Polysomnography (sleep study),” “EEG (Electroencephalogram,” “Is it OK to use over-the-counter antihistamines to treat insomnia? I’d like to avoid prescription sleep aids.”

Psychological Bulletin: “(Mis)perception of sleep in insomnia: a puzzle and a resolution.”

Harvard Health Publishing: “Are drugstore sleep aids safe?”

Sleep Medicine Review: “The Role of Sleep Hygiene in Promoting Public Health: A Review of Empirical Evidence.”

Stanford Health Care: “Stimulus Control and CBTI.”

University of Michigan Health: “Stress Management: Doing Progressive Muscle Relaxation.”

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