14: SLEEP STATE MISPERCEPTION

This is one of the issues considered in Section 4 and in Step E.

Also called “paradoxical insomnia” (ICSD, p. 27), this condition is characterized by a person’s belief that he/she is getting an unreasonably small amount of sleep over a long period of time.

14a. Initial Evidence

Basically, the person’s reports of insomnia are so extreme (Manber and Org, p. 114) as to be not believable

  • Reports of a pattern of little or no sleep on all or most nights. This might even be found in the patient’s sleep log as well, which is a subjective if formal report.
  • No apparent need to catch up with naps or extra-long days. A patient may also report not feeling tired during the day.
  • Contradictory evidence from objective measurements such as actigraph records or reports from a sleep lab.
  • Despite the perceived lack of sleep, the person seems physiologically and psychologically within normal ranges. There is no apparent consequence of the loss.

Information on when and how the problem can be helpful in understanding the person’s concerns. These need consideration, even if observation is lacking.

14b. Subjective Underestimates

There is a normal tendency for people with insomnia to underestimate the amount of time they have slept, so it is possible that a patient who complains of lack of sleep is getting more than he/she thinks (Reite, Weissberg and Ruddy, pp 71-73). However, a person who claims to be getting 2-3 hours of sleep at night and functions adequately during the day without naps is probably misjudging his/her sleep. A normal amount is usually considered to be five or more hours per night, and that much sleep loss can’t be sustained. By contrast, good sleepers tend to overestimate their sleep time and underestimate the amount of time it takes them to get to sleep (ICSD, p. 35).

It is difficult for many people to assess the amount of sleep they are getting with any real accuracy, for a variety of reasons.

  • Most people don’t really pay attention, but they still may have a sense that they are not getting enough, or that they are getting too much.
  • They haven’t kept a sleep log, so even their estimates are vague.
  • Their sleep times change from day to day and are hard to remember.
  • They don’t want to think about the time when they are falling asleep.
  • They may think they are asleep when they are awake, and the reverse.

Commonly we gather information about a person’s daily functioning as a cross-check on his/her insomnia. However, often when people think they slept poorly, they also experience sleepiness the following day, so these sources of information are not independent (Manber and Ong, p.118).

14c. Subjective Overestimates

It is also possible that a person is getting less sleep than he/she realizes, but this is not commonly a complaint. Some people may mask their sleep loss through nighttime medications, daytime stimulants, frantic activity, and so on.

14d. Objective Estimates

There are temperature, respiration, activity and brain wave indicators of sleep that can be assessed independently of the patients experience. Usually these are carried out in a sleep laboratory, where the patient spends the night. Records are obtained, including a polysomnogram or EEG, and compared to the person’s report of sleep time. Some evidence can also be obtained through use of an actigraph.

These measures may not always be accurate. Morin (p. 35) suggests that the way sleep is measured may miss some rapid shifts in sleep stages that can be interpreted by the person as being awake. In that case, one should be cautious in saying that the person is misperceiving his/her sleep state.

14d. Further Evidence for Misperception

You can ask about dreams and bedtime fantasies – how vivid they are, and what they are about. A person may think he/she is awake and actually be in light sleep. A person may remember being awake when he/she was actually dozing, either on going to sleep or on awakening.

In sleep deprivation studies, it was observed that after a long enough amount of deprivation, subjects actually kept going by taking tiny naps of even a few seconds, so it appeared that they were continuously awake.

DAYTIME CONSEQUENCES

Ask how sleepy the person is during the day, and whether there is an urgent need to take naps. A person who is missing sleep should feel a strong need to “catch up” during the day.

Ask about performance – if it is degraded due to fatigue, that could be a cue that the person is losing sleep, or that sleep is ineffective.

If it turns out that a person reports getting adequate sleep when using a sleep log and is still sleepy during the day, the issue is still open but it may not be a problem of misperception.

Anxiety at bedtime and depression during the day (Section 10) can be sources of misperception and distorted time estimates.

This might be a good time to use a sleep record If the person keeps close account of amount of time sleeping – including broken sleep and naps – it may be convincing that sleep is adequate.

If the sleep log shows very little sleep at night, and the person is not sleepy during the day, misperception is still a possibility. The person is filling out the sleep log and may be misreading the cues for sleep. It is possible that what the patient calls sleepiness Is actually fatigue, tiredness, or boredom (Morin, 12)

There are also published scales for assessing a person’s insomnia (see a review in Germain and Moul, pp. 90-93). It is not clear whether these are clinically useful in individual treatment. They might be helpful in getting a person to examine his/her perceptions from new perspectives.

14e. Treatment

It is not clear how to treat a person who is convinced he/she has serious insomnia with no confirming evidence.

You can evaluate the accuracy of the person’s estimates by comparing them to actual observations in a sleep laboratory. It would seem that referral to a sleep lab could be informative to a therapist, but the patient, confronted with the results, may remain convinced of lack of sleep and continue to show related symptoms.

Some people are so convinced of their problem that they feel damaged and in danger despite reassurances to the contrary. Professional dismissal of their perceptions can lead to the seeking of additional referrals in addition to feelings of hopelessness, depression, and cynicism. They may resort to alcohol and other substances as self-management strategies.

It is also possible that a person who appears to be sleeping normally according to objective criteria may have typical symptoms of sleep deprivation. Morin (p.35) has argued that EEG technology may miss some aspects of sleep that patients are responding to.

Depth of sleep varies throughout the night for everyone. We all go through nightly cycles, and part of each cycle involves very light sleep (Section 40). Many people awaken several times and believe that they take a long time to return to sleep. Some people may interpret dreaming or light sleep as being awake. Some psycho-education on sleep cycles might be helpful to normalize the person’s perceptions. Especially if there are no apparent daytime consequences of the issue, the person may be able to treat it as a variable of living and move on.

This might be a time to review earlier treatment approaches. Perhaps the person has chronic fatigue or a medication side effect that wasn’t caught before. If the person remembers dreams, an effort to analyze them may uncover conflicts that are otherwise unrecognized. Pursuit of that material may resolve enough to relieve pressure about insomnia.

Sleep restriction therapy (Section 29) might be helpful in getting a person to a reasonable balance in which his/her perception of insomnia is having less impact on daily life. Spielman, Yang, and Glovinsky (p. 286) suggest starting the person with very little time in bed (under 5 hours a night) and increasing slowly. Their experience is that a patient may have improved daytime functioning but continue to complain of poor sleep efficiency.