Sleepless Yet Asleep: A Case Report on Paradoxical Insomnia
Abstract
Background: Paradoxical insomnia, also termed sleep state misperception, is a subtype of chronic insomnia in which a patient's subjective report of severely disturbed or absent sleep is markedly discordant with objective evidence of normal sleep duration and architecture on polysomnography. Patients typically overestimate sleep-onset latency and underestimate total sleep time, often without the daytime impairment expected of comparable objective sleep loss. Case Report: We report the case of a 51-year-old married woman with a 15-month history of perceived total sleep loss, constant wakefulness, and early morning awakening, without objective daytime sleepiness. Serial Pittsburgh Sleep Quality Index (PSQI) scores remained abnormal despite sequential trials of dothiepin, mirtazapine, clonazepam, quetiapine, zolpidem, and melatonin. Sleep diaries maintained during inpatient evaluation documented adequate sleep, and nocturnal polysomnography and the Hamilton Depression Rating Scale (HDRS) were within normal limits, confirming a diagnosis of paradoxical insomnia. Intervention and Outcome: The patient was managed with psychoeducation and cognitive behavioural therapy (CBT) targeting misperception of sleep, incorporating sleep diaries and sleep hygiene techniques, with sustained clinical improvement. Conclusion: This case emphasizes the need for objective sleep assessment in patients with treatment-refractory insomnia and shows that CBT is an effective, medication-sparing strategy…
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