What is Sleep State Misperception (Paradoxical Insomnia)?

By Jennifer Walker-Journey

Sleep state misperception (SSM), also called paradoxical insomnia, pseudo-insomnia, or subjective insomnia, is a condition in which someone mistakenly perceives their sleep as wakefulness and as a result severely underestimates their sleep time. 

This can cause sufferers to develop anxiety and depression because they mistakenly think they are suffering from insomnia

While anyone may make these types of errors from time to time, sleep state misperception is considered a sleep disorder when the misperception becomes ingrained or chronic.

What is Sleep State Misperception (SSM)?

Sleep state misperception is considered to be a rare sleep disorder, though some question whether it is a disorder at all. People with SSM usually have little to no daytime impairment, unlike what is often seen in people who suffer from insomnia. Furthermore, the results of a polysomnography, or sleep study, show normal sleep patterns with no evidence of a sleep disorder.

It is believed that SSM is a type of hypochondria, and treatment often involves cognitive behavioral therapy for underlying anxiety or depression. Sedatives may be prescribed to help relieve symptoms. In some cases, having the patient understand normal sleep patterns is enough to alleviate anxiety about their perceived lack of sleep.  

Conversely, there is a related condition called reverse sleep state misperception, also called positive sleep state misperception, in which people feel that they have slept much longer than they actually have. 

Common Symptoms of SSM

SSM is a poorly understood sleep disorder. It is estimated that about 5% of the population suffer from sleep state misperception, and that it mostly affects young to middle-aged adults. However, the fact that people with SSM are both psychiatrically and medically healthy may indicate the condition is largely underreported. 

Symptoms of sleep state misperception include:

  • Severe insomnia. 
  • Feeling that you’ve had several years of no sleep, short sleep, or non-restorative sleep.
  • Being otherwise healthy (psychiatrically and medically speaking) and without the level of impairment that is normally expected with such a level of sleep deprivation.
  • Heightened awareness of surroundings when lying down. 
  • Excessive thinking during the night but with little recall of what you were thinking. 

Conversely, insomnia can be defined by the following symptoms: 

  • Taking more than 30 minutes to fall asleep. 
  • Waking during the night and having trouble returning to sleep. 
  • Waking earlier than desired.
  • Daytime symptoms such as fatigue, moodiness, sleepiness, or reduced energy.
  • Getting less than 7 hours of sleep each night. 

How is SSM Diagnosed? 

Diagnosis of SSM is generally made based on the following three criteria:

  1. Patient complains of insomnia and
    1. Has sleep of a normal duration and quality, and
    2. Results from a polysomnography, or sleep study, show normal sleep patterns.
  2. There are no mental or psychiatric disorders that would cause the person to complain of insomnia without a sleep deficit.
  3. Other sleep disorders that can lead to insomnia are not present to the degree that would explain the patient’s complaint. 

How to Treat SSM

There are a few treatments for people suffering from sleep state misperception:

  • Sedative hypnotics, such as prescription Ambien or over-the-counter Benadryl. However, these medications may have side effects such as withdrawal and dependence. 
  • Cognitive behavioral therapy has been shown effective for some people with underlying anxiety or depression. 
  • Education of sleep-wake cycles can help suffers of SSM better understand their disorder and, as a result, lessen anxiety. 
  • Electroconvulsive therapy, also called electroshock therapy, has been shown to be both safe and effective in patients with severe depression resulting from a fear of insomnia caused by SSM.

Summary

Sleep state misperception is a poorly understood sleep disorder that can adversely affect quality of life. It occurs when someone mistakenly perceives their sleep as wakefulness and as a result severely underestimates their sleep time. 

These individuals will complain that they suffer from insomnia when in fact they do not exhibit any symptoms of sleep deprivation. While some people may feel some nights that they didn’t get as much sleep as they actually did, SSM becomes a concern when the misperception becomes ingrained or chronic. The reassuring news is that effective treatment is available. 


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