Non-restorative sleep

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Non-restorative sleep (NRS), also known as unrefreshing sleep, [1] is a subjective symptom in which sleep is experienced as insufficiently refreshing and hence subjective sleep quality as poor. [2] [3] This can be despite the appearance of otherwise normal sleep, like adequate sleep duration and lack of nighttime awakenings. [2] [3] NRS is associated with daytime cognitive dysfunction, affective symptoms, fatigue, sleepiness, and increased pain. [2] [3] [4] It is diagnosed exclusively via self-report or sleep questionnaires. [2] [5]

Contents

Conditions

NRS is often a symptom of sleep disorders such as insomnia and shift work sleep disorder. [2] [3] It can also occur in hypersomnia and narcolepsy. [2] [3] In addition, NRS is frequently a symptom of conditions like fibromyalgia, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), long COVID, autoimmune disorders like rheumatoid arthritis and systemic lupus erythematosus (SLE), and infections. [2] [3] [6] [4] [7] NRS has been especially associated with fibromyalgia and ME/CFS, with approximately 65 to 95% of people with fibromyalgia and 85 to 95% of people with ME/CFS reporting unrefreshing sleep. [2] [3] [4] NRS may in fact be related to the cognitive impairment, fatigue, and myalgia (muscle pain) experienced by people with fibromyalgia and ME/CFS. [3] [4] Other conditions associated with NRS include sleep apnea, periodic limb movement disorder (PLMD), and chronic pain. [2] [3] [4] Psychiatric disorders such as depression or anxiety have been associated with NRS as well. [2] [3] On the other hand, NRS can occur without any comorbidity. [2] [3]

Correlates

Older age is strongly correlated with NRS, although conflicting findings exist. [3] In addition, women experience NRS more often than men, though this is not always observed. [3] Relatedly, in the case of fibromyalgia, more than 90% of people with this condition are women. [2] [4] People who are unemployed or retired have been found to experience more NRS than employed people. [3] Shift workers have a relatively high level of NRS. [3] Moderate to high stress has been associated with NRS. [3]

Causes

Research on the mechanisms underlying NRS are controversial and inconclusive. [2] [3] NRS is correlated with sleep onset latency and to a lesser extent with sleep duration. [3] The symptom might be due to disturbance of slow wave sleep (SWS; non-REM sleep or "deep sleep") and due to insufficiently deep sleep. [3] [2] [4] Alternatively or additionally, it might be related to REM sleep deprivation. [4] Pro-inflammatory cytokines such as interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor α (TNFα) may have negative effects on sleep and increase the likelihood of NRS. [2] These findings provide a possible mechanism by which immune disorders and related conditions may affect sleep and cause NRS. [2]

Treatment

There is little information available on treatment of NRS as of 2008. [3] [4] Treatments that might be helpful in some cases of NRS include behavioral measures like cognitive–behavioral therapy (CBT) and hypnotherapy, exercise, hypnotics, and certain antidepressants. [4] Some hypnotics have been found to improve SWS, such as sodium oxybate (γ-aminobutyric acid; GHB) and gaboxadol, and hypnotics of this sort might be more useful than other hypnotics in the treatment of NRS, but more research is needed to substantiate such notions. [4] [8] [9]

References

  1. ↑ https://meassociation.org.uk/nice-guidelines/items/unrefreshing-sleep/
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Wilkinson K, Shapiro C (June 2012). "Nonrestorative sleep: symptom or unique diagnostic entity?". Sleep Med. 13 (6): 561–569. doi:10.1016/j.sleep.2012.02.002. PMID   22560828.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Stone KC, Taylor DJ, McCrae CS, Kalsekar A, Lichstein KL (August 2008). "Nonrestorative sleep". Sleep Med Rev. 12 (4): 275–288. doi:10.1016/j.smrv.2007.12.002. PMID   18539057.
  4. 1 2 3 4 5 6 7 8 9 10 11 Moldofsky H (March 2008). "The significance, assessment, and management of nonrestorative sleep in fibromyalgia syndrome". CNS Spectr. 13 (3 Suppl 5): 22–26. doi:10.1017/s1092852900026808. PMID   18323770.
  5. ↑ Vernon MK, Dugar A, Revicki D, Treglia M, Buysse D (June 2010). "Measurement of non-restorative sleep in insomnia: A review of the literature". Sleep Med Rev. 14 (3): 205–212. doi:10.1016/j.smrv.2009.10.002. PMID   20018533.
  6. ↑ Lee, Elliott K; Auger, R. Robert (23 April 2024). "Sleep and Long COVID—A Review and Exploration of Sleep Disturbances in Post Acute Sequelae of SARS-COV-2 (PASC) and Therapeutic Possibilities". Current Sleep Medicine Reports. 10 (2): 169–180. doi:10.1007/s40675-024-00299-4. ISSN   2198-6401 . Retrieved 21 September 2025.
  7. ↑ Livieratos A, Lockley SW, Tsiodras S (February 2025). "Post infectious fatigue and circadian rhythm disruption in long-COVID and other infections: a need for further research". EClinicalMedicine. 80: 103073. doi:10.1016/j.eclinm.2025.103073. PMC   11787434 . PMID   39896874.{{cite journal}}: CS1 maint: article number as page number (link)
  8. ↑ Wafford KA, Ebert B (February 2006). "Gaboxadol—a new awakening in sleep". Curr Opin Pharmacol. 6 (1): 30–36. doi:10.1016/j.coph.2005.10.004. PMID   16368265.
  9. ↑ Walsh JK (April 2009). "Enhancement of slow wave sleep: implications for insomnia". J Clin Sleep Med. 5 (2 Suppl): S27 –S32. PMC   2824211 . PMID   19998872.


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