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Sleep state misperception

sleep state misperception, sleep state misperception disorder
Sleep state misperception SSM is a term in the International Classification of Sleep Disorders ICSD most commonly used for people who mistakenly perceive their sleep as wakefulness,12 though it has been proposed that it be applied to those who severely overestimate their sleep time as well3 "positive" sleep state misperception4 While most sleepers with this condition will report not having slept in the previous night at all or having slept very little,5 clinical recordings generally show normal sleep patterns Though the sleep patterns found in those with SSM have long been considered indistinguishable from those without, some preliminary research suggest there may be subtle differences see Symptoms and diagnosis: Spectral analysis6

Patients are otherwise generally in good health,1 and any ills—such as depression—appear to be more associated with fear of negative consequences of insomnia "insomnia phobia" than from any actual loss of sleep7

Sleep state misperception was adopted by the ICSD to replace two previous diagnostic terminologies: "subjective insomnia complaint without objective findings" and "subjective sleepiness complaint without objective findings"1

Other synonyms of the term include: paradoxical insomnia, pseudo-insomnia, subjective insomnia, subjective sleepiness, and sleep hypochondriasis1


  • 1 Classification
  • 2 Prevalence
  • 3 Symptoms and diagnosis
    • 31 Diagnostic criteria
    • 32 Detection and difficulties
    • 33 Spectral analysis
  • 4 Treatment
    • 41 Complications
  • 5 Distinction from "true" insomnia
  • 6 See also
  • 7 References


Sleep state misperception is classified as an intrinsic dyssomnia89 While SSM is regarded a sub-type of insomnia, it is also established as a separate sleep-condition, with distinct pathophysiology110 Nonetheless, the value of distinguishing this type of insomnia from other types is debatable due to the relatively low frequency of SSM being reported3

Sleep state misperception can also be further broken down into several types, by patients who—

  • report short sleep subjective insomnia complaint without objective findings1
    • or no sleep at all subjective total insomnia2
  • report excessive daytime sleepiness subjective sleepiness complaint without objective findings1
  • report sleeping too much subjective hypersomnia without objective findings411


SSM is poorly understood As of 2008, there is little to no information regarding risk factors or prevention,1 though it is believed to be most prevalent among young to middle aged adults3

Distribution among the general population and by gender is unknown About 5% of the clinical population may be affected,3 though that figure is subject to sampling bias

Symptoms and diagnosisedit

Sleep waves EEG highlighted above recorded from those with SSM may appear indistinguishable from those without

This sleep disorder frequently applies when patients report not feeling tired despite their subjective perception of not having slept12 Generally, they may describe experiencing several years of no sleep, short sleep, or non-restorative sleep Otherwise, patients appear healthy, both psychiatrically and medically1 That this condition is often asymptomatic could explain why it is relatively unreported

However, upon clinical observation, it is found that patients may severely overestimate the time they took to fall asleep—often reporting having slept half the amount of time indicated by polysomnogram or electroencephalography EEG, which may record normal sleep5 Observing such discrepancy between subjective and objective reports, clinicians may conclude that the perception of poor sleep is primarily illusionary

Alternatively, some people may report excessive daytime sleepiness or chronic disabling sleepiness, while no sleep disorder has been found to exist1 Methods of diagnosing sleepiness objectively, such as the Multiple Sleep Latency Test do not confirm the symptom—"true" sleepiness is not observed despite the complaint13 It may be speculated that such reports of daytime sleepiness may be a result of the nocebo responsecitation needed —the reverse of the placebo effect—due to patient expectations of adverse effects from their subjective perception of poor sleep

Finally, on the opposite end of the spectrum, other patients may report feeling that they have slept much longer than is observed13 It has been proposed that this experience be subclassified under sleep state misperception as "positive sleep state misperception", "reverse sleep state misperception", and "negative sleep state misperception"

Diagnostic criteriaedit

The patient has a complaint of insomnia while sleep quality and duration are normal Polysomnographic monitoring demonstrates normal sleep latency, a normal number of arousals and awakenings, and normal sleep duration with or without a multiple sleep latency test that demonstrates a mean sleep latency of greater than 10 minutes No medical or mental disorder produces the complaint Other sleep disorders producing insomnia are not present to a degree that would explain the patient’s complaint

Detection and difficultiesedit

Detecting sleep state misperception by objective means has been elusive13 One woman affected by SSM began contemplating suicide "because no one can figure out what is wrong with me" after being repeatedly dismissed as normal by various doctors and receiving insomnia treatments that did not work from others7

A 2011 study published in the journal Psychosomatic Medicine has shown that sleep misperception ie, underestimation of sleep duration is prevalent among chronic insomniacs who sleep objectively more than 6 hours in the sleep lab The psychological profile of these chronic insomniacs with objective normal sleep duration is characterized by depressive, anxious-ruminative traits and poor coping resources Thus, it appears that not all chronic insomniacs underestimate their sleep duration, and that sleep misperception is a clinical characteristic of chronic insomniacs with objective normal sleep duration Furthermore, rumination and poor coping resources may play a significant role in sleep misperception14

Spectral analysisedit

According to a May 2014 article published in NewScientist, spectral analysis may help clinicians find objective evidence for sleep state misperception:

it uncovered subtle differences in the EEGs of sleeping insomniacs: alpha waves – signatures of wakefulness that are supposed to show up only in early sleep – were intruding into deep sleep psychologist and sleep researcher Michael Perlis But Andrew Krystal of Duke University in Durham, North Carolina, used spectral analysis to quantify just how much they were intruding Krystal's non-sleepers not only had a greater proportion of these alpha disturbances, but the alpha waves were bigger and the delta waves were correspondingly smaller That wasn't all When Perlis and other researchers applied spectral analysis algorithms to the EEGs of their sleeping insomniacs, they found different patterns, fast waves known as beta and gamma Sleep, vol 24, p 110 Normally, these are indicators of consciousness, alertness and even anxiety Like alpha waves, Perlis calls these beta and gamma waves "intrusions" into normal sleep: "It's as if somebody is playing with the switch – boop, boop – flipping at a mad rate between wake and sleep," 6


Behavioral treatment can be effective in some cases1 Sedative hypnotics may also help relieve the symptoms15 Additionally, education about normal patterns of the sleep-wake cycle may alleviate anxiety in some patients1 For patients with severe depression resulting from the fear of having insomnia, electroconvulsive therapy appears to be a safe and effective treatment7


The condition may worsen as a result of persistent attempts to treat the symptoms through conventional methods of dealing with insomnia The prescription of hypnotics or stimulants may lead to drug dependency as a complication1

Nonetheless, chronic SSM may increase risk for depression, anxiety, and substance abuse3 It has also been noted that patients with this condition may sometimes opt to take medications over other treatments "for the wrong reasons eg because of euphoriant properties"16

Distinction from "true" insomniaedit

What is considered objective insomnia, unlike SSM, can easily be confirmed empirically through clinical testing, such as by polysomnogram16 Those who experience SSM may believe that they have not slept for extended periods of time, when they in fact do sleep but without perceiving it For example, while patients who claim little or no sleep may usually acknowledge impaired job performance and daytime drowsiness, sleep state misperceivers often do not17

Cases of objective total insomnia are extremely rare The few that have been recorded have predominantly been ascribed to a rare incurable genetic disorder called fatal familial insomnia, which patients rarely survive for more than 26 months after the onset of illness—often much less18 While rarer cases of objective total insomnia lasting for decades have been reported, such as with the American Al Herpin and the Vietnamese Thai Ngoc, they have not been studied extensively in a clinical setting1920

See alsoedit

  • Second wind sleep
  • Somniphobia
  • Hypochondriasis


  1. ^ a b c d e f g h i j k l m n Minecan, Daniela, and Antonio Culebras http://wwwmedlinkcom/web_content/MLT0003Saspdead link "Sleep state misperception" MedLink Neurology Originally published: September 6, 1995 Updated: October 29, 2008
  2. ^ a b McCall, WV; Edinger, JD 1992 "Subjective total insomnia: an example of sleep state misperception" Sleep 15 1: 71–3 PMID 1557596 
  3. ^ a b c d e f Kushida, Clete A Handbook of Sleep Disorders Informa Health Care, 2008 ISBN 0-8493-7319-0, ISBN 978-0-8493-7319-0 Page 32
  4. ^ a b Trajanovic, N; Radivojevic, V; Kaushansky, Y; Shapiro, C 2007 "Positive sleep state misperception – A new concept of sleep misperception" Sleep Medicine 8 2: 111–8 doi:101016/jsleep200608013 PMID 17275407 
  5. ^ a b Insomnia Causes Healthcommunitiescom Original Publication: 01 Dec 2000 Updated: 01 Dec 2007
  6. ^ a b Finkbeiner, Ann 2014, "Awake asleep: Insomniac brains that can't switch off", NewScientist 2969: 34, archived from the original on 2014-09-09 
  7. ^ a b c Case, K; Hurwitz, TD; Kim, SW; Cramer-Bornemann, M; Schenck, CH 2008 "A case of extreme paradoxical insomnia responding selectively to electroconvulsive therapy" Journal of Clinical Sleep Medicine 4 1: 62–3 PMC 2276826  PMID 18350965 
  8. ^ Dysomnia causes Icantgetnosleepinfo November 4, 2009unreliable medical source
  9. ^ The International Classification of Sleep Disorders Holisticonlinecomunreliable medical source
  10. ^ Edinger, J; Krystal, AD 2003 "Subtyping primary insomnia: is sleep state misperception a distinct clinical entity" Sleep Medicine Reviews 7 3: 203–14 doi:101053/smrv20020253 PMID 12927120 
  11. ^ Coleman, R M; Roffwarg, HP; Kennedy, SJ; Guilleminault, C; Cinque, J; Cohn, MA; Karacan, I; Kupfer, DJ; et al 1982 "Sleep-wake disorders based on a polysomnographic diagnosis A national cooperative study" JAMA 247 7: 997–1003 doi:101001/jama2477997 PMID 7057593 
  12. ^ Insomnia Information Sleepnetcom - Insomnia Informationunreliable medical source
  13. ^ a b Conroy, Deirdre A; Culebras, Antonio 2013 "Paradoxical insomnia" 
  14. ^ Fernandez-Mendoza J, Calhoun S, Bixler E, Karataraki M, Liao D, Vela-Bueno A, Ramos-Platon M, Sauder K, Basta M, Vgontzas A "Sleep Misperception and Chronic Insomnia in the General Population: The Role of Objective Sleep Duration and Psychological Profiles" Psychosomatic Medicine, 2011; 731: 88-97 doi:101097/PSY0b013e3181fe365a
  15. ^ Hauri PJ "Primary insomnia" Principles and practice of sleep medicine 2nd ed Philadelphia: WB Saunders, 1994page needed
  16. ^ a b Littner, M; Hirshkowitz, M; Kramer, M; Kapen, S; Anderson, WM; Bailey, D; Berry, RB; Davila, D; et al 2003 "Practice parameters for using polysomnography to evaluate insomnia: an update" Sleep 26 6: 754–60 PMID 14572131 
  17. ^ Paradoxical Insomnia
  18. ^ Schenkein, Joyce Fatal Familial Insomnia Part 1: What Is Fatal Familial Insomnia Medscape
  19. ^ http://wwwtheepochtimescom/n2/content/view/2855/ Ngoc Thai: The Man Who Doesn’t Sleep
  20. ^ The Man Who Never Slept: Fatal Familial Insomnia and Total Sleep Deprivation

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