All About Paradoxical Insomnia: A Rare Condition Between Sleep and Wakefulness

Most cases of insomnia fit into one of three broad categories: trouble falling asleep, waking throughout the night, or waking too early in the morning. But in rare cases, patients may have another type, paradoxical insomnia, that doesn't fit so clearly within these guidelines.

Patients with paradoxical insomnia often report spending hours lying awake at night, even though, to others, they appear to be sleeping. They overestimate the time it takes for them to fall asleep and underestimate their total sleep time.

Paradoxical insomniacs have an intense awareness of their surroundings throughout the entire night, as if they were awake. They might think they've gone without sleep for days at a time, but with only moderate signs of daytime fatigue.

A surprise diagnosis
Suzy Watson, 26, was diagnosed with paradoxical insomnia after she answered an advertisement for a sleep trial at a local Chicago university. A loud snorer (to the point where she sometimes woke herself up), Watson believe she was suddenly taking hours to fall asleep and waking up frequently all night long.

"My nights were dreadful," says the marketing manager. "I felt like I was getting about three to five hours of sleep, and those were on 'good' nights. I felt OK during the day, but I did notice that I had a shorter attention span at work, and I forgot things easily—places I'd just eaten, or what movies I'd recently watched were about."

Watson assumed that her sleep study would reveal obstructive sleep apnea, since it ran in the family; her father had surgery to treat his.

At the hospital sleep center, Watson was wired with electrodes on her head and body, belts around her chest and abdomen, and a small clip on her fingertip.

"The technician put sticky sensor things all over my face, in my hair, on my neck, on my chest, she says. "It was really uncomfortable. I thought, There is no way I'm going to sleep tonight in this little hospital bed."

The next morning, Watson felt completely sleep-deprived—but the research doctor later informed her otherwise: "I was told that I slept seven hours. If you had asked me, I would have said two hours, because that's what it felt like. I was completely shocked."

She was also surprised to learn that her snoring—the result of a deviated septum—was not serious enough to obstruct her breathing or be considered sleep apnea. Her real problem, it turned out, was paradoxical insomnia.

Finding a solution
Watson was relieved to find out that there was a real explanation for her symptoms, and the diagnosis helped her doctor understand her condition better. They worked together, trying Tylenol PM, over-the-counter melatonin, and, when those weren't helpful, a variety of prescription sleep drugs. These have helped, but Watson is hoping that her next visit with a sleep specialist will improve her sleep even more.

While insomnia is the most common sleep problem in the U.S. (affecting an estimated 35% of the population), it's estimated that less than 5% of those cases can be considered paradoxical.

The American Academy of Sleep Medicine has more information on paradoxical insomnia and other uncommon sleep disorders at its patient website, SleepEducation.com. If you or your sleep partner are experiencing these symptoms, talk to a certified sleep specialist.