MY INSOMNIA STARTED at age 15. Each night, I’d lie down to sleep and drift off pretty quickly, only to reawaken an hour or so later. Then I’d remain half awake for hours—eyes forced shut, stealing only a few glances at the alarm clock, mind churning with just one anxiety that seemed to grow in the darkness: When will I possibly go back to sleep?
Maybe you’ve felt that way too. At least 25 percent of Americans experience insomnia each year, according to a recent study by the University of Pennsylvania. And rates tend to spike during times of peak anxiety, which would be, like, right now (for so many reasons). For many people, these problems are temporary—they last for just a few weeks—but after 19 years of restless nights, my waking nightmare felt more or less permanent.
It tends to come in long bursts followed by shorter periods of relief, but at its worst points I feel like I’ve slept maybe one or two hours a night. If sleep is a calm ocean of relaxation, I was the guy constantly skimming the surface. Eventually, I’d submerge just before dawn broke only to be rudely awakened by the shrill call of my alarm.
But here's the twist: Whenever my partner stirs and looks over, he swears that I am actually asleep. My eyes are closed, I’m breathing slowly—sometimes I’m even snoring. I never believed him but that posed a question as ridiculous as it was eerie: Was I awake or was I asleep? And how, come to think of it, are we really supposed to know the difference?
HERE'S WHAT THE typical insomnia experiment looks like: Participants spend the night in a laboratory while scientists measure their brain’s activity through electrodes placed on the scalp (a technique known as electroencephalography, or EEG for short). The next morning, the participants estimate how much they have slept, and this figure is compared with the objective measures of the electrical recordings.
But in 1972 researchers at Stanford noted a strange anomaly. For many us, the reality and our perception of it is wildly different. “[People] have slept for most of the night, but they complain that they have slept very little or not at all,” explains Dr. Bernd Feige, Ph.D., a sleep specialist at the University of Freiburg in Germany.
Today, that physiological and mental disconnect holds a strange promise for people who wake up feeling like they’ve tossed and turned. The condition is apparently fairly common, and if it is better recognized and treated, might help many of us sleep better at night without much effort or medication.
It’s called paradoxical insomnia, and the latest research suggests that those suffering from the condition are not really awake but trapped in a bad dream limbo that simulates being awake. And that can get exhausting. If you’re a paradoxical insomniac, you likely wake up anxious, concerned that you’re going to be exhausted, with the sort of heightened stress that makes this cycle continually repeat. That sounded a lot like me.
The bigger question is, if you knew that, could you stop it? Many researchers believe that’s possible. But so far, even defining the condition (also called pseudoinsomnia) and establishing its prevalence and causes has been a challenge. The American Psychiatric Association has yet to formulate an official diagnostic process, so sleep labs have often used different thresholds to gauge the prevalence of the phenomenon. That’s complicated by the fact that all insomniacs generally overestimate their sleep loss to some degree, so it’s been hard to determine clear criteria for when this misperception should be considered the primary problem.
Recent research by Professor Mauro Manconi, Ph.D., at the Neurocenter of Southern Switzerland, however, suggests that people who are off 90 percent or more in their subjective sleep estimates are likely paradoxical sufferers. (For example, for every six hours you sleep, you might claim you were out for only about 36 minutes total.) Patients with this level of misperception don’t respond to the most common insomnia medications. (In the U.S. today, insomnia is most commonly treated with so called “sedative-hypnotic” drugs; the most popular is zolpidem, which is prescribed to more than 5 million patients each year.) “So we are dealing with something very different,” says Manconi.
With this definition, around one in six people diagnosed with insomnia are really paradoxical insomniacs who are being treated with existing therapies that may be ill suited to their true condition. If you consider other potential measures, such as a 50 percent error in the patients’ estimation of the time it takes to get to sleep (rather than the total sleep time), then the prevalence can rise to more than 60 percent. And that doesn’t account for everyone suffering without seeking medical help, who may be self-medicating with everything from booze to natural remedies and over-the-counter sleep aids.
The upshot is that a lot of people—potentially millions of us—may not be caring for ourselves correctly. On the other hand, if you (much like me) feel like you’ve never had any lasting relief from, well, anything, there’s at least an explanation.
A DECADE AGO, the chief explanation for paradoxical insomnia was that people with the condition are simply light sleepers, and are likely to awake briefly throughout the night. Although those short periods of awareness might not make much difference to the overall quantity of sleep, the regular awakenings could be enough to create the impression of prolonged sleeplessness.
In recent years, as more studies have advanced, researchers have speculated that the mismatch between objective and subjective sleep measures is caused by small pockets of heightened brain activity in an otherwise sleeping brain. If so, it’s a little like the way that dolphins sleep with half of their brain at a time—one brain hemisphere sleeps while the other remains alert to control their breathing and swimming. Except dolphins seem to remain pretty chipper.
“People may base their judgment on whether they are asleep or not on the activity of these brain regions,” says Professor Daniel Kay, Ph.D, a sleep scientist at Brigham Young University. In his sleep lab, Kay has used a different kind of brain-scanning technique called positron emission tomography, or PET, to record the activity of people’s deeper brain regions. He found that the perception of being awake coincided with heightened activity in what he refers to as the brain’s “hot zone of conscious awareness.” EEG recordings can’t pick up on this deeper, regionalized activity; they only register the slowing of activity at the surface of the brain, which appears to resemble normal sleep.
While that may explain some people’s paradoxical insomnia, it can’t rule out other theories that may apply to other patients. An analysis by Feige’s Germany-based team offers the tantalizing possibility that some cases of paradoxical insomnia may arise from an inability to distinguish dreams from reality. Over the course of a night, the brain cycles between two different types of sleep—rapid eye movement (REM) sleep, when we dream, and “quiescent” sleep, which tends to involve fewer dreams. Each type has its own signature of electrical activity, and these are both different from waking activity.
To investigate the possibility that we may be mistaking dreams for waking consciousness, Feige concocted a study that resembles an insomniac’s true nightmare: His team invited 54 participants (including 27 self-identified insomniacs) to spend four nights in his sleep lab and woke them at various points to find out what they were experiencing.
The results, published in 2018, showed few differences between healthy sleepers and insomniacs during quiescent (non-REM) sleep, but a huge divide during REM sleep, with around a third of the “insomniac” patients claiming to have been awake during that period—when their brain activity suggested that they were in fact lost in dreams. The healthy sleepers, in contrast, “practically never said that they had been awake when awoken from REM sleep.”
From these results, the team hypothesizes that a healthy sleeper has vivid fantasies so obviously different from their waking state that it is easy to recognize that they’ve been asleep. For the paradoxical insomniac, however, dreams are full of the rumination that they would be having if they were actually awake, making the two states indistinguishable: Their “insomnia” is really a dream about insomnia.
Feige thinks this could arise from general anxieties that seep into the unconscious. “Dream content is something that you take from your daytime experience into sleep,” he says. “If you go to sleep with positive emotions then it’s more likely that your dreams will also show these positive emotions. But if you go to sleep with worries, then it’s more likely that your dreams will reflect those worries.”
These three theories may all be true. The brief micro-awakenings, the localized conscious brain activity, and the misinterpreted dreams could work together to create your misperception; each may play a role in the experience.
A greater understanding of these processes could offer tailored treatments for fake sleep sufferers. Feige, for instance, points out that cognitive behavioral therapy is already available to alter other types of recurring dreams and nightmares. It involves revisiting the events of the dream and rewriting the script with a happier ending. If paradoxical insomnia really is a ruminative dream, then a similar approach might help us avoid its reappearing in the future.
A few months ago, I decided to try it out myself. During the day, I’d try to reimagine the fretful nighttime state in which my mind is whirring with worries, and then imagine my thoughts slowing down until I was in a kind of meditative calmness, looking forward to the day ahead rather than agonizing over sleep loss. If my “insomnia” was really a dream, I reasoned, this could produce a more restful night. When I got into bed each night, I also gave myself something new to focus on: not sheep, exactly, but counting down from 1,000, which helps me avoid priming my brain with ruminations about my insomnia.
Today I usually conk out at around 925. But the main difference is that I then stay asleep a lot longer. I can’t say I’m fully cured, but the periods of (perceived) sleeplessness appear to be losing their grip. Sometimes I still feel like I’m skimming the surface of unconsciousness, but I’m calmer about it. It feels like I’m clocking around six or seven out of eight hours of good sleep, which is pretty normal.
More than anything, the simple realization that my body can be asleep even if my brain is signaling something slightly different has helped relieve some of the anxiety in my daily life. My dreams today tend to be mundane but pleasant, without the incessant rumination that once haunted them—and that’s incredibly refreshing.
