Sleep state misperception

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Sleep state misperception
Other namesParadoxical insomnia, pseudo-insomnia, subjective insomnia, subjective sleepiness, sleep hypochondriasis [1]
Specialty Sleep medicine

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, [1] [2] though it has been proposed that it be applied to those who severely overestimate their sleep time as well [3] ("positive" sleep state misperception). [4] 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 analysis). [6]

Contents

Patients are otherwise generally in good health, [1] and any illnesses—such as depression—appear to be more associated with fear of negative consequences of insomnia ("insomnia phobia") than from any actual loss of sleep. [7]

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]

The validity and reliability of sleep state misperception as a pertinent diagnosis has been questioned, [8] with studies finding poor empirical support. [9]

Classification

Sleep state misperception is classified as an intrinsic dyssomnia. [10] [ unreliable medical source? ] [11] [ unreliable medical source? ] While SSM is regarded a sub-type of insomnia, it is also established as a separate sleep-condition, with distinct pathophysiology. [1] [12] Nonetheless, the value of distinguishing this type of insomnia from other types is debatable due to the relatively low frequency of SSM being reported. [3]

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

Validity

The validity and reliability of the sleep state misperception as a pertinent medical entity was questioned. [8] A study found poor empirical support for this diagnostic item. [9]

Symptoms and diagnosis

Sleep waves (EEG highlighted above) recorded from those with SSM may appear indistinguishable from those without. Sleep EEG Stage 1.jpg
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 slept. [14] [ unreliable medical source? ] Generally, they may describe experiencing several years of no sleep, short sleep, or non-restorative sleep. Otherwise, patients appear healthy, both psychiatrically and medically. [1] (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 sleep. [5] 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 exist. [1] Methods of diagnosing sleepiness objectively, such as the Multiple Sleep Latency Test, do not confirm the symptom—objective sleepiness is not observed despite the complaint. [15]

Finally, on the opposite end of the spectrum, other patients may report feeling that they have slept much longer than is observed. [15] 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 criteria

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 difficulties

Detecting sleep state misperception by objective means has been elusive. [1] [3]

A 2011 study published in the journal Psychosomatic Medicine has shown that sleep misperception (i.e., 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 misperception. [16]

Spectral analysis

According to a May 2014 article published in New Scientist , 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]

Distinction from insomnia

What is considered objective insomnia, unlike SSM, can easily be confirmed empirically through clinical testing, such as by polysomnogram. [17] 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 not. [18]

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 less. [19]

Treatment

Behavioral treatment can be effective in some cases. [1] Sedative hypnotics may also help relieve the symptoms. [20] Additionally, education about normal patterns of the sleep-wake cycle may alleviate anxiety in some patients. [1] For patients with severe depression resulting from the fear of having insomnia, electroconvulsive therapy appears to be a safe and effective treatment. [7]

Complications

A subject who is not being monitored (by a recording or other observer) may not have a way to tell if a treatment is working properly due to the amnesic nature of SSM.

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 complication. [1]

Nonetheless, chronic SSM may increase risk for depression, anxiety, and substance abuse. [3] It has also been noted that patients with this condition may sometimes opt to take medications over other treatments "for the wrong reasons (e.g. because of euphoriant properties)." [17]

Epidemiology

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 adults. [3]

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.

See also

Related Research Articles

Paradoxical intention (PI) is a psychotherapeutic technique used to treat recursive anxiety by repeatedly rehearsing the anxiety-inducing pattern of thought or behaviour, often with exaggeration and humor. Paradoxical intention has been shown to be effective in treating psychosomatic illnesses such as chronic insomnia, public speaking phobias, etc. by making patients do the opposite of their hyper-intended goal, hindering their ability to perform the activity.

<span class="mw-page-title-main">Sleep disorder</span> Medical disorder of a persons sleep patterns

A sleep disorder, or somnipathy, is a medical disorder of an individual's sleep patterns. Some sleep disorders are severe enough to interfere with normal physical, mental, social and emotional functioning. Sleep disorders are frequent and can have serious consequences on patients’ health and quality of life. Polysomnography and actigraphy are tests commonly ordered for diagnosing sleep disorders.

<span class="mw-page-title-main">Insomnia</span> Inability to fall or stay asleep

Insomnia, also known as sleeplessness, is a sleep disorder where people have trouble sleeping. They may have difficulty falling asleep, or staying asleep for as long as desired. Insomnia is typically followed by daytime sleepiness, low energy, irritability, and a depressed mood. It may result in an increased risk of accidents of all kinds as well as problems focusing and learning. Insomnia can be short term, lasting for days or weeks, or long term, lasting more than a month. The concept of the word insomnia has two possibilities: insomnia disorder (ID) and insomnia symptoms, and many abstracts of randomized controlled trials and systematic reviews often underreport on which of these two possibilities the word insomnia refers to.

<span class="mw-page-title-main">Delayed sleep phase disorder</span> Chronic mismatch between a persons normal daily rhythm, compared to other people and societal norms

Delayed sleep phase disorder (DSPD), more often known as delayed sleep phase syndrome and also as delayed sleep–wake phase disorder, is the delaying of a person's circadian rhythm compared to those of societal norms. The disorder affects the timing of biological rhythms including sleep, peak period of alertness, core body temperature, and hormonal cycles.

Dyssomnias are a broad classification of sleeping disorders involving difficulty getting to sleep, remaining asleep, or of excessive sleepiness.

Somnolence is a state of strong desire for sleep, or sleeping for unusually long periods. It has distinct meanings and causes. It can refer to the usual state preceding falling asleep, the condition of being in a drowsy state due to circadian rhythm disorders, or a symptom of other health problems. It can be accompanied by lethargy, weakness and lack of mental agility.

Hypersomnia is a neurological disorder of excessive time spent sleeping or excessive sleepiness. It can have many possible causes and can cause distress and problems with functioning. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), hypersomnolence, of which there are several subtypes, appears under sleep-wake disorders.

<span class="mw-page-title-main">Sleep hygiene</span> Set of practices around healthy sleeping

Sleep hygiene is a behavioral and environmental practice developed in the late 1970s as a method to help people with mild to moderate insomnia. Clinicians assess the sleep hygiene of people with insomnia and other conditions, such as depression, and offer recommendations based on the assessment. Sleep hygiene recommendations include: establishing a regular sleep schedule; using naps with care; not exercising physically or mentally too close to bedtime; limiting worry; limiting exposure to light in the hours before sleep; getting out of bed if sleep does not come; not using bed for anything but sleep and sex; avoiding alcohol as well as nicotine, caffeine, and other stimulants in the hours before bedtime; and having a peaceful, comfortable and dark sleep environment. However, as of 2021, the empirical evidence for the effectiveness of sleep hygiene is "limited and inconclusive" for the general population and for the treatment of insomnia, despite being the oldest treatment for insomnia. A systematic review by the AASM concluded that clinicians should not prescribe sleep hygiene for insomnia due to the evidence of absence of its efficacy and potential delaying of adequate treatment, recommending instead that effective therapies such as CBT-i should be preferred.

Non-24-hour sleep–wake disorder is one of several chronic circadian rhythm sleep disorders (CRSDs). It is defined as a "chronic steady pattern comprising [...] daily delays in sleep onset and wake times in an individual living in a society". Symptoms result when the non-entrained (free-running) endogenous circadian rhythm drifts out of alignment with the light–dark cycle in nature. Although this sleep disorder is more common in blind people, affecting up to 70% of the totally blind, it can also affect sighted people. Non-24 may also be comorbid with bipolar disorder, depression, and traumatic brain injury. The American Academy of Sleep Medicine (AASM) has provided CRSD guidelines since 2007 with the latest update released in 2015.

Periodic limb movement disorder (PLMD) is a sleep disorder where the patient moves limbs involuntarily and periodically during sleep, and has symptoms or problems related to the movement. PLMD should not be confused with restless legs syndrome (RLS), which is characterized by a voluntary response to an urge to move legs due to discomfort. PLMD on the other hand is involuntary, and the patient is often unaware of these movements altogether. Periodic limb movements (PLMs) occurring during daytime period can be found but are considered as a symptom of RLS; only PLMs during sleep can suggest a diagnosis of PLMD.

<span class="mw-page-title-main">Somnology</span> Scientific study of sleep

Somnology is the scientific study of sleep. It includes clinical study and treatment of sleep disorders and irregularities. Sleep medicine is a subset of somnology.

<span class="mw-page-title-main">Ramelteon</span> Hypnotic medication

Ramelteon, sold under the brand name Rozerem among others, is a melatonin agonist medication which is used in the treatment of insomnia. It is indicated specifically for the treatment of insomnia characterized by difficulties with sleep onset. It reduces the time taken to fall asleep, but the degree of clinical benefit is small. The medication is approved for long-term use. Ramelteon is taken by mouth.

Circadian rhythm sleep disorders (CRSD), also known as circadian rhythm sleep-wake disorders (CRSWD), are a family of sleep disorders which affect the timing of sleep. CRSDs arise from a persistent pattern of sleep/wake disturbances that can be caused either by dysfunction in one's biological clock system, or by misalignment between one's endogenous oscillator and externally imposed cues. As a result of this mismatch, those affected by circadian rhythm sleep disorders have a tendency to fall asleep at unconventional time points in the day. These occurrences often lead to recurring instances of disturbed rest, where individuals affected by the disorder are unable to go to sleep and awaken at "normal" times for work, school, and other social obligations. Delayed sleep phase disorder, advanced sleep phase disorder, non-24-hour sleep–wake disorder and irregular sleep–wake rhythm disorder represents the four main types of CRSD.

The International Classification of Sleep Disorders (ICSD) is "a primary diagnostic, epidemiological and coding resource for clinicians and researchers in the field of sleep and sleep medicine". The ICSD was produced by the American Academy of Sleep Medicine (AASM) in association with the European Sleep Research Society, the Japanese Society of Sleep Research, and the Latin American Sleep Society. The classification was developed as a revision and update of the Diagnostic Classification of Sleep and Arousal Disorders (DCSAD) that was produced by both the Association of Sleep Disorders Centers (ASDC) and the Association for the Psychophysiological Study of Sleep and was published in the journal Sleep in 1979. A second edition, called ICSD-2, was published by the AASM in 2005. The third edition, ICSD-3, was released by the AASM in 2014. A text revision of the third edition (ICSD-3-TR) was published in 2023 by the AASM.

<span class="mw-page-title-main">Sleep medicine</span> Medical specialty devoted to the diagnosis and therapy of sleep disturbances and disorders

Sleep medicine is a medical specialty or subspecialty devoted to the diagnosis and therapy of sleep disturbances and disorders. From the middle of the 20th century, research has provided increasing knowledge of, and answered many questions about, sleep–wake functioning. The rapidly evolving field has become a recognized medical subspecialty in some countries. Dental sleep medicine also qualifies for board certification in some countries. Properly organized, minimum 12-month, postgraduate training programs are still being defined in the United States. In some countries, the sleep researchers and the physicians who treat patients may be the same people.

<span class="mw-page-title-main">Sleep deprivation</span> Condition of not having enough sleep

Sleep deprivation, also known as sleep insufficiency or sleeplessness, is the condition of not having adequate duration and/or quality of sleep to support decent alertness, performance, and health. It can be either chronic or acute and may vary widely in severity. All known animals sleep or exhibit some form of sleep behavior, and the importance of sleep is self-evident for humans, as nearly a third of a person's life is spent sleeping.

Idiopathic hypersomnia(IH) is a neurological disorder which is characterized primarily by excessive sleep and excessive daytime sleepiness (EDS). The condition typically becomes evident in early adulthood and most patients diagnosed with IH will have had the disorder for many years prior to their diagnosis. As of August 2021, an FDA-approved medication exists for IH called Xywav, which is oral solution of calcium, magnesium, potassium, and sodium oxybates; in addition to several off-label treatments (primarily FDA-approved narcolepsy medications).

Cognitive behavioral therapy for insomnia (CBT-I) is a technique for treating insomnia without medications. Insomnia is a common problem involving trouble falling asleep, staying asleep, or getting quality sleep. CBT-I aims to improve sleep habits and behaviors by identifying and changing the thoughts and the behaviors that affect the ability of a person to sleep or sleep well.

<span class="mw-page-title-main">Behavioral sleep medicine</span>

Behavioral sleep medicine (BSM) is a field within sleep medicine that encompasses scientific inquiry and clinical treatment of sleep-related disorders, with a focus on the psychological, physiological, behavioral, cognitive, social, and cultural factors that affect sleep, as well as the impact of sleep on those factors. The clinical practice of BSM is an evidence-based behavioral health discipline that uses primarily non-pharmacological treatments. BSM interventions are typically problem-focused and oriented towards specific sleep complaints, but can be integrated with other medical or mental health treatments. The primary techniques used in BSM interventions involve education and systematic changes to the behaviors, thoughts, and environmental factors that initiate and maintain sleep-related difficulties.

Sleep problems in women can manifest at various stages of their life cycle. Both subjective and objective data indicate that women are at an increased risk of experiencing different types of sleeping problems during different life stages. Factors such as hormonal changes, aging, psycho-social aspects, physical and psychological conditions, and the presence of sleeping disorders can disrupt women's sleep. Research supports the presence of disturbed sleep during the menstrual cycle, pregnancy, postpartum period, and menopausal transition. The relationship between sleep and women's psychological well-being suggests that the underlying causes of sleep disturbances are often multi-factorial throughout a woman's lifespan.

References

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  5. 1 2 Insomnia Causes. Healthcommunities.com. Original Publication: 01 Dec 2000. Updated: 01 Dec 2007.
  6. 1 2 Finkbeiner, Ann (2014), "Awake asleep: Insomniac brains that can't switch off", New Scientist (2969): 34, archived from the original on 2014-09-09
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  11. ↑ The International Classification of Sleep Disorders. Holisticonline.com
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  14. ↑ Insomnia Information Sleepnet.com - Insomnia Information
  15. 1 2 Conroy, Deirdre A; Culebras, Antonio (2013). "Paradoxical insomnia".
  16. ↑ 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; 73(1): 88-97. doi : 10.1097/PSY.0b013e3181fe365a
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  18. ↑ Paradoxical Insomnia
  19. ↑ Schenkein, Joyce Fatal Familial Insomnia. Part 1: What Is Fatal Familial Insomnia. Medscape.
  20. ↑ Hauri PJ. "Primary insomnia." Principles and practice of sleep medicine. 2nd ed. Philadelphia: WB Saunders, 1994.[ page needed ]
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