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Paradoxical Insomnia

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  Related Treatments
Cognitive Behavioral Therapy (CBT)

What is it?

Paradoxical insomnia is a complaint of severe insomnia. It occurs without objective evidence of any sleep disturbance. Daytime effects vary in severity. But they tend to be far less severe than one would expect given the expressed sleep complaints. People with this disorder often report little or no sleep for one or more nights. They also describe having an intense awareness of the external environment or internal processes consistent with being awake. This awareness suggests a state of hyperarousal.

A key feature is an overestimation of the time it takes them to fall asleep. They also underestimate their total sleep time. Another feature is that the degree of sleep deprivation reported seems improbable. Their level of daytime functioning is likely to be only moderately impaired. Objective findings of fairly normal sleep duration and quality tend to result from an overnight sleep study. These findings are much different from their perception of poor quality sleep.

Who gets it?

Insomnia is the most common sleep problem in the U.S. Estimates are that it affects 10% to 35% of people in the U.S. at least some of the time. But paradoxical insomnia is fairly uncommon. Less than 5% of people with insomnia symptoms have paradoxical insomnia. In general, insomnia is more common in women than men. But the exact gender rates for this disorder are unclear. Younger and middle-aged people are most likely to develop paradoxical insomnia. Those with it are likely to have overactive minds prior to bedtime or while lying in bed.

How do I know if I have it?

First, you need to determine if you might have insomnia by answering the following questions:

  1. Do you have trouble falling asleep or staying asleep, or do you wake up too early or feel unrefreshed after sleeping?
  2. Does this problem occur even though you have the opportunity and the time to get a good night’s sleep?
  3. Do you have at least one of the following problems?
  • Low energy
  • Lack of motivation
  • Attention, concentration or memory problems
  • Poor performance at school or work
  • Extreme mood changes
  • Daytime sleepiness
  • Trouble making errors at work or while driving
  • Tension, headaches or stomach aches
  • Frustration or worry about your sleep

If you answered yes to these questions, then you might have insomnia. Now continue to see if you might have paradoxical insomnia:

1. Has the insomnia been present for at least one month?

2. Does one or more of the following apply?

  • You have a chronic pattern of little or no sleep most nights. Nights of normal amounts of sleep are rare.
  • Sleep diary data show total sleep times well below what is normal for your age.
  • Objective findings from a sleep study show your sleep to be much more normal than you perceive it to be.

3. Does at least one of the following apply?

  • You report constant or near constant awareness of what is happening in your bedroom environment throughout most nights.
  • You report that your mind is actively engaged in thinking while you lie in bed throughout most nights.

4. Is your level of daytime impairment fairly mild compared to the severe level of sleep loss that you report?

If you answered “yes” to these questions, then you might have paradoxical insomnia.

It is also important to know if there is something else that is causing your sleep problems. They may be a result of one of the following:

  • Another sleep disorder
  • A medical condition
  • Medication use
  • A mental health disorder
  • Substance abuse

Do I need to see a sleep specialist?

A sleep specialist is the best person to evaluate your sleep problem. He or she will help you rule out any other possible sources of complaints related to insomnia.

What will the doctor need to know?

The doctor will need to know when the insomnia began. He or she will want to know how often it occurs and any factors that trigger it. The doctor will need to know your complete medical history. Be sure to inform him or her of any past or present drug and medication use.

Also tell your doctor if you or any family members have ever had any other sleep disorder. It will also be helpful if you fill out a sleep diary for two weeks. This is a simple diary that records the following information:

  • The time you went to bed
  • How long it took you to fall to sleep
  • The number and duration of awakenings at night
  • What time you got out of bed for the day

The sleep diary will help the doctor see your typical sleeping patterns. This data gives the doctor clues about what is causing your problem and how to correct it.

Will I need to take any tests?

Yes. To be sure that you have paradoxical insomnia, you need to do an overnight sleep study in a sleep lab. This study is called a polysomnogram. It measures the amount and quality of sleep you obtain during the night. The results can then be compared to your perceptions.

A diagnosis of paradoxical insomnia can only be made if there is a big difference between the sleep study results and your perception of sleep quality. An overnight sleep study is not needed for most other complaints of insomnia. But it is likely to be used if you have signs and symptoms of other types of sleep problems. This includes sleep apnea or periodic limb movements. Your sleep specialist can help you decide if a sleep study is needed in your case.

How is it treated?

These are the two primary approaches to the treatment of insomnia:

1. Pharmacological therapy (medications)
This involves common sleeping pills such as the following:

  • Ambien®
  • Lunesta
  • Trazadone
  • Over-the-counter sleep aids

2. Cognitive Behavioral Therapy
This is a strategy designed to improve sleep by promoting changes in behavior. Common techniques include the following:

  • Stimulus control therapy: You go to bed only when sleepy. You get out of bed to do something relaxing if you can not sleep.
  • Sleep restriction therapy: You reduce the number of hours spent in bed. This total more closely matches the actual number of hours spent sleeping.
  • Relaxation exercises: Methods of breathing, meditating, and relaxing the muscles are used to improve your sleep.
  • Sleep hygiene therapy: This consists of basic habits and tips that help you develop a pattern of healthy sleep. It includes such things as avoiding caffeine and stimulants in the evening hours.

    By Donald R. Townsend, PhD
    Updated October 21, 2005

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