Sleep state misperception
|Sleep state misperception|
|Classification and external resources|
|ICD-9||307.42, 307.49, 780.52|
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, though it has been proposed that it be applied to those who severely overestimate their sleep time as well ("positive" sleep state misperception). While most sleepers with this condition will report not having slept in the previous night at all or having slept very little, clinical recordings demonstrate superficially normal sleep patterns. Recent research shows real differences in the brain wave patterns of people who believe they were awake when they really were asleep and normal sleep, see Symptoms and diagnosis. 
Patients are otherwise generally in good health, and any ills—such as depression—appear to be more associated with fear of negative consequences of insomnia ("insomnia phobia") than from any actual loss of sleep.
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."
Other synonyms of the term include: paradoxical insomnia, pseudo-insomnia, subjective insomnia, subjective sleepiness, and sleep hypochondriasis.
Sleep state misperception is classified as an intrinsic dyssomnia. While SSM is regarded a sub-type of insomnia, it is also established as a separate sleep-condition, with distinct pathophysiology. Nonetheless, the value of distinguishing this type of insomnia from other types is debatable due to the relatively low frequency of SSM being reported.
Sleep state misperception can also be further broken down into several types, by patients who—
- report short sleep (subjective insomnia complaint without objective findings)
- or no sleep at all (subjective total insomnia)
- report excessive daytime sleepiness (subjective sleepiness complaint without objective findings)
- report sleeping too much (subjective hypersomnia without objective findings)
Symptoms and diagnosis
This sleep disorder frequently applies when patients report not feeling tired despite their subjective perception of not having slept. Alternatively, patients may report excessive daytime sleepiness or insomnia, while lacking factors often associated with those symptoms such as sleep apnea syndrome or another sleep disorder. Generally, they may describe experiencing several years of no sleep, short sleep, or non-restorative sleep. Otherwise, patients appear healthy, both psychiatrically and medically. (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. Thus, it becomes evident that the perception of poor sleep is primarily illusionary.
Despite the above brain wave patterns of pseudoinsomniacs are different from those of normal sleep.
(...) 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," 
Reports of daytime sleepiness may be a result of the nocebo response —the reverse of the placebo effect—due to patient expectations of adverse effects from their subjective perception of poor sleep. Alternatively patients may be suffering from poor quality sleep as the recent research into brain wave patterns shows. 
This complaint depends on patient self-reporting of sleep, and was not measurable by objective means. before the Andrew Krystal studies.  One woman affected by SSM began contemplating suicide “because no one can figure out what is wrong with me” after being repeatedly dismissed as normal by various doctors and receiving insomnia treatments that did not work from others.
A recent 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.
Behavioral treatment can be effective in some cases. Sedative hypnotics may also help relieve the symptoms. Additionally, education about normal patterns of the sleep-wake cycle may alleviate anxiety in some patients. For patients with severe depression resulting from the fear of having insomnia, electroconvulsive therapy appears to be a safe and effective treatment.
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.
Nonetheless, chronic SSM may increase risk for depression, anxiety, and substance abuse. 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)."
Distinction from "true" insomnia
What is considered objective insomnia, unlike SSM, can easily be confirmed empirically through clinical testing, such as by polysomnogram. 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 so and they sleep differently form normal sleepers. 
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. While rarer cases of objective total insomnia lasting for decades have been reported, such as with the American Al Herpin and the Vietnamese Thai Ngoc, they have not been studied extensively in a clinical setting.
- Minecan, Daniela, and Antonio Culebras. http://www.medlink.com/web_content/MLT0003S.asp[dead link] "Sleep state misperception." MedLink Neurology. Originally published: September 6, 1995. Updated: October 29, 2008.
- McCall, WV; Edinger, JD (1992). "Subjective total insomnia: an example of sleep state misperception". Sleep 15 (1): 71–3. PMID 1557596.
- Kushida, Clete A. Handbook of Sleep Disorders. Informa Health Care, 2008. ISBN 0-8493-7319-0, ISBN 978-0-8493-7319-0. (Page 32)
- Trajanovic, N; Radivojevic, V; Kaushansky, Y; Shapiro, C (2007). "Positive sleep state misperception – A new concept of sleep misperception". Sleep Medicine 8 (2): 111–8. doi:10.1016/j.sleep.2006.08.013. PMID 17275407.
- Insomnia Causes. Healthcommunities.com. Original Publication: 01 Dec 2000. Updated: 01 Dec 2007.
- Do You Feel Like You're Not Sleeping, Even When You Are?
- Case, K; Hurwitz, TD; Kim, SW; Cramer-Bornemann, M; Schenck, CH (2008). "A case of extreme paradoxical insomnia responding selectively to electroconvulsive therapy". Journal of clinical sleep medicine 4 (1): 62–3. PMC 2276826. PMID 18350965.
- Dysomnia causes. Icantgetnosleep.info. November 4, 2009[unreliable medical source?]
- The International Classification of Sleep Disorders. Holisticonline.com[unreliable medical source?]
- Edinger, J; Krystal, AD (2003). "Subtyping primary insomnia: is sleep state misperception a distinct clinical entity?". Sleep Medicine Reviews 7 (3): 203–14. doi:10.1053/smrv.2002.0253. PMID 12927120.
- Coleman, R. M.; Roffwarg, HP; Kennedy, SJ; Guilleminault, C; Cinque, J; Cohn, MA; Karacan, I; Kupfer, DJ et al. (1982). "Sleep-wake disorders based on a polysomnographic diagnosis. A national cooperative study". JAMA 247 (7): 997–1003. doi:10.1001/jama.247.7.997. PMID 7057593.
- Insomnia Information Sleepnet.com - Insomnia Information[unreliable medical source?]
- New Scientist, 17th May 2014 page 34. The New Scientist article, also by Finkbeiner starts on page 33 and has the title, "Fast Awake and Wide Asleep".
- Hauri PJ. "Primary insomnia." Principles and practice of sleep medicine. 2nd ed. Philadelphia: WB Saunders, 1994.[page needed]
- Littner, M; Hirshkowitz, M; Kramer, M; Kapen, S; Anderson, WM; Bailey, D; Berry, RB; Davila, D et al. (2003). "Practice parameters for using polysomnography to evaluate insomnia: an update". Sleep 26 (6): 754–60. PMID 14572131.
- Schenkein, Joyce Fatal Familial Insomnia. Part 1: What Is Fatal Familial Insomnia. Medscape.
- http://www.theepochtimes.com/n2/content/view/2855/ Ngoc Thai: The Man Who Doesn’t Sleep
- The Man Who Never Slept: Fatal Familial Insomnia and Total Sleep Deprivation