Reconsidering sleep perception in insomnia: from misperception to mismeasurement

Abstract

SummarySo‐called ‘sleep misperception’ refers to a phenomenon in which individuals have the impression of sleeping little or not at all despite normal objective measures of sleep. It is unknown whether this subjective–objective mismatch truly reflects an abnormal perception of sleep, or whether it results from the inability of standard sleep recording techniques to capture ‘wake‐like’ brain activity patterns that could account for feeling awake during sleep. Here, we systematically reviewed studies reporting sleep macro‐ and microstructural, metabolic, and mental correlates of sleep (mis)perception. Our findings suggest that most individuals tend to accurately estimate their sleep duration measured with polysomnography (PSG). In good sleepers, feeling awake during sleep is the rule at sleep onset, remains frequent in the first non‐rapid eye movement sleep cycle and almost never occurs in rapid eye movement (REM) sleep. In contrast, there are patients with insomnia who consistently underestimate their sleep duration, regardless of how long they sleep. Unlike good sleepers, they continue to feel awake after the first sleep cycle and importantly, during REM sleep. Their mental activity during sleep is also more thought‐like. Initial studies based on standard PSG parameters largely failed to show consistent differences in sleep macrostructure between these patients and controls. However, recent studies assessing sleep with more refined techniques have revealed that these patients show metabolic and microstructural electroencephalography changes that likely reflect a shift towards greater cortical activation during sleep and correlate with feeling awake. We discuss the significance of these correlates and conclude with open questions and possible ways to address them.

Neurophysiological Parameters Influencing Sleep–Wake Discrepancy in Insomnia Disorder: A Preliminary Analysis on Alpha Rhythm during Sleep Onset

“…This finding is consistent with the evidence in the literature reporting that the NREM sleep of ID patients is characterized by more cortical activation than in healthy con-trols. Several studies have reported an increase in alpha [13,[44][45][46], sigma [13,44,45], beta [13,17,[44][45][46], gamma [17,46,47] frequencies and a decrease in delta frequencies [17,[44][45][46] during an entire night's NREM sleep [48]. It was also found that ID patients exhibited increased beta frequencies even during diurnal sleep, as observed in multiple sleep latency tests (MSLTs), and those with lower sleep efficiency and longer latency to MLST showed higher beta power also during night sleep [49].…”

Assessing the Accuracy of Generative Conversational Artificial Intelligence in Debunking Sleep Health Myths: Mixed Methods Comparative Study With Expert Analysis

“…For instance, “sleep state misperception,” also known as “paradoxical insomnia,” is a condition where individuals believe they are awake for most of the night, despite actually sleeping for a normal duration. This disorder is characterized by a significant discrepancy between perceived and actual sleep time, often associated with personality traits like neuroticism and altered brain activity during sleep, though its causes and prevalence remain under investigation [ 27 - 30 ].…”

Embracing sleep onset complexity

“…Like behavioural responsiveness, subjective sleep perception does not align well with sleep stages [62][63][64][65]. Participants often overestimate their sleep onset latency: 26-50% of them still feel awake after the appearance of the first sleep spindle (N2 ; [1,62,66]). This overestimation of sleep latency could be linked to the asynchronous cortical deactivation found during the SOP, with some cortical areas that are still 'awake' (see previous Section).…”