“But doc”, Jason insisted, “I know for a FACT that I slept only two or three hours last night! I was awake most of the night! I was thinking about how to improve sales at the restaurant, and I know I had some good ideas. I just wish I could remember them more clearly…”
Jason, a young and ambitious man in his early thirties, is typical of the patients I’ve seen who have a particular type of insomnia. These patients often report getting very little sleep and yet seem to function reasonably well. For example, a patient may report averaging only three hours of sleep per night, and yet be able to do reasonably well on the job without experiencing daytime drowsiness. Indeed the complaint is usually of being unable to nap even when given the opportunity.
What is going on here? Usually getting only a few hours of sleep will result in sleep deprivation. This results in memory difficulty, difficulty focusing, deep fatigue, sleepiness and automatic behaviors. Automatic behaviors occur when the person engages in activities but has no memory of them. We have all probably experienced some sleep debt and the automatic behaviors that can go with it, such as realizing that we have poured a cup of coffee but don’t clearly remember doing it. It is as if the person is on automatic pilot. The potential of falling asleep at the wheel or while operating machinery or mission critical software is also a significant danger with seep deprivation.
This doesn’t happen with people like Jason. He and those like him experience such intense insomnia that they believe that they are getting almost no sleep at all despite spending a significant amount of time in bed. As it turns out, sleep studies have revealed that people sometimes have great difficulty accurately estimating how long it takes them to fall asleep and just how long they are awake during the night. People who misperceive the sleep state they are in just aren’t good at making these estimates. This is most likely due to high levels of arousal that keep the brain more active even during sleep and make judgments of wakefulness versus sleep difficult.
When using cognitive behavioral treatment methods for insomnia we often rely on subjectively completed sleep journals, as these are useful even for people like Jason who are greatly misperceiving the amount of sleep they are getting. Using the technique of bed restriction, nightly time spent in bed is reduced to slightly more than the average estimated nightly sleep time that the person reported having over the previous week or two. For Jason, who reported averaging four hours of sleep per night despite spending seven hours in bed, this meant decreasing time in bed to just five hours per night. This technique results in deeper sleep for a number of reasons. Because people are up longer during the day the drive to sleep is increased resulting in deeper sleep. Frustrating time awake in bed is decreased, resulting in less arousal that worsens insomnia. Poor quality sleep that is easily misperceived as wakefulness is reduced as sleep is deepened. As sleep is deepened, it is more restorative. If people have indeed been sleeping more than they think they have because of sleep state misperception and use sleep restriction they will notice that the reduced amount of sleep is likely to be deeper and more restorative. Jason was pleasantly surprised at how much better he felt after spending less, not more, time in bed! So what is his diagnosis, and in addition to bed restriction, what can be done to help?
People who greatly misperceive the amount of time they are asleep during the night and suffer from non-restorative, poor quality sleep and daytime fatigue are diagnosed with paradoxical insomnia. A major focus of cognitive restructuring in this case is to help the patient recognize that in fact they are indeed getting more sleep than they thought.
Paradoxical insomnia is sleep state misperception, “insomnia without objective findings”. The level of daytime impairment is not equal to that which one expects from the lack of sleep reported. Often patients will report that their spouse has claimed they were asleep, when they were fairly certain that they were actually awake. Sleep studies typically confirm that objectively measured sleep is of greater quantity than that subjectively reported. Patients are not malingering and are often surprised that they slept as much as the study indicates that they did. Like Jason, they may initially have a hard time believing that they actually slept as much as the sleep study indicates. This type of insomnia results from over-arousal affecting sleep such that the person spends more time in lighter stages of sleep and has more ongoing cognitive activity in these lighter stages. Is it often the case that patients with paradoxical insomnia will report excessive thinking during the night but have relatively little recall of its content.
A complicating factor is that many people with insomnia will actually sleep better in the laboratory, despite the novelty and discomfort of being observed while trying to sleep in an unfamiliar bed with many electrodes attached to the head and body. These patients have conditioned arousal to being in their own bed and bedroom and actually sleep much better in a novel, even less comfortable, setting. They are used to not sleeping well in their own bed; not sleeping well at home has become a conditioned response. For these patients, being in the lab at sleep time is a break from this pattern and so they sleep better.
For Jason and others with paradoxical insomnia, however, the sleep lab experience is one of taking longer to get to sleep and of being awake more during the night than the sleep study demonstrates. They do not feel that they slept better in the laboratory.
Paradoxical insomnia is found in only about 5 percent of patients who present for treatment of insomnia. Young and middle aged adults tend to have a greater prevalence of paradoxical insomnia, and it often starts in young adulthood and middle age. It is relatively uncommon among children. Several factors increase the risk of paradoxical insomnia. These include depressive traits, excessive central nervous system activation during sleep and excessive mentation before and during sleep.
While paradoxical sleep can often be treated effectively with cognitive behavioral strategies such as sleep restriction and cognitive restructuring, it can persist for months or years if left untreated. Of even greater concern is that sleep may continue to deteriorate over time and develop into more severe forms of insomnia while increasing the risk of depression, anxiety and dependency on sleeping medication.
If you or someone you know is suffering from insomnia it is a good idea to get it evaluated and treated as soon as possible, otherwise there is a risk of the conditioning worsening and notably decreasing enjoyment of life. The good news is, relief from insomnia is available to you. Whether you, like Jason, are one of the 5 perecent who have paradoxical insomnia, or whether your insomnia is of the more typical sort, cognitive and behavioral techniques can indeed successfully alleviate your symptoms- and help you once again enjoy restorative, refreshing, sleep. ZZZzzzzzzz…