For the past two years, I have suffered from serious insomnia. Whenever I would speak up about my frustration over having been awake all night, however, my husband always told me I had slept soundly the whole time. The comments my friends and colleagues made also hinted at their uncertainty about what I was going through. I did not look like I was struggling with insomnia, they told me, because I never seemed overly tired, and I could be competent in my routine work. Disputes about my health became a regular occurrence in my daily life.

A series of medical examinations that I hoped would provide an answer showed no abnormal findings. Still, I continued to seek treatment for my insomnia and took many kinds of hypnotic medications. None of them were effective, and I felt increasingly tormented—not only because of the insomnia itself, but also because of a loss of trust from my husband and friends. They said they wondered whether I was pretending just to get sympathy.

When polysomnography showed my total sleep time, I couldn't believe it. Not only did the study results report seven hours and 18 minutes of sleeping, but my sleep efficiency was 87%. My physician told me that I was experiencing paradoxical insomnia, which involves underestimating actual sleep time. After receiving cognitive behavior therapy, I began to feel much better and now am able to sleep well most of the time.—l.c.j.

COMMENTARY

Paradoxical insomnia, which has previously been called sleep state misperception and subjective insomnia, is the reporting of severe insomnia without corroborative objective evidence of sleep disturbance or significant impairment of daytime function. Patients who have this relatively uncommon form of insomnia have a marked propensity to underestimate sleep duration and overestimate wakefulness relative to polysomnographic measures. Cognitive behavior therapy for insomnia includes sleep hygiene education, stimulus control, sleep restriction, relaxation, and cognitive therapy, and is an effective treatment for paradoxical insomnia. Our patient underestimated her actual sleep time because of irrational beliefs and excessive worry about sleep. She can now correctly estimate her sleep time and only occasionally feels like she is experiencing insomnia. Her relationship with her husband and friends has improved.