The sleep onset complaint group was then divided into a subjective insomnia group and an objective insomnia group, based on the ratio of self-reported sleep latency to objective latency to stage 2 sleep of the night in question. A morning questionnaire assessing subjective quality of sleep and an Eysenck’s Personality Inventory (EPI) was administered to these subjects as well. The subjects then participated in an experimental night (under polysomnographic monitoring) followed by an experimental day (multiple sleep latency testing). This was based on an administered sleep questionnaire which looked at duration of reported sleep latency, frequency of prolonged sleep latency and chronicity of prolonged sleep latency. ![]() In 1997, Dorsey et al looked at 31 undergraduates in a 19 hour experimental protocol where each subject was classified into one of two groups, a sleep onset complaint group and a non-complaint group. We will look at both lines of arguments and evaluate the evidence behind them. The second hypothesis is that sleep discrepancy has a physiological basis, but we have yet to elucidate the processes behind it. The first hypothesis is that sleep discrepancy in insomnia is a completely subjective phenomenon, a pure perception error and that there is no other basis for the observation. We will divide this section along the lines of 2 possible hypothesis. So if this misperception is common to all patients suffering from insomnia, is there an explanation on why this happens? We will attempt in this essay to explore the reasons put forth in the literature that might help resolve this observation. In the American Academy of Sleep Medicine clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults published in 2017, they described sleep misperception to be characteristic of all insomnia disorders, varying only in extent. ![]() This diagnosis is best made with concurrent polysomnographic and self-reported sleep scores (11). However the objective measures of sleep do not correlate with the degree of daytime symptoms. According to the ICSD-2, the hallmark of paradoxical insomnia is that the patient complains of severe and near total insomnia. On the other end of the spectrum is paradoxical insomnia. This represents a small proportion of patients who had daytime symptoms despite reporting adequate sleep. Overestimation of objective sleep, meaning that patients were exhibiting worse sleep then they were reporting, was described by Trajanovic et al as positive sleep state misperception (10). Sleep discrepancy is a spectrum and can vary from an underestimation of sleep to an overestimation of sleep. Also known as “pseudo-insomnia” and “sleep state misperception”. The common observation is an underestimation of total sleep time, an overestimation of sleep onset latency and an overestimation of wakening after sleep onset. These findings were consistently reported in subsequent studies against objective measures of polysomnography (7, 8) and even actigraphy (9). In 1976, Carskadon et al compared the sleep laboratory recordings of 122 chronic insomniacs with their subjective sleep assessments and reported that most subjects underestimated their total sleep time and overestimated the sleep onset latency (6). ![]() The discrepancy between recorded objective sleep and reported subjective sleep, also known as sleep discrepancy, has long been observed in insomnia. It is a common observation for patients suffering from insomnia to report less sleep than what they are observed to have. Current treatment strategies have limitations and best practice guidelines have been developed to aid in diagnosis and treatment of chronic insomnia (4,5). Unfortunately, insomnia therapy is a challenging issue. There is a need to identify, diagnose and treat chronic insomnia. Insomnia is also associated an increased risk of developing other comorbidities such as psychiatric illnesses and heart failure (3). These symptoms may include fatigability, reduced alertness, mood disturbances, poor concentration with impairment at work or school and reduced quality of life (2). It is characterized by the inability to initiate or maintain sleep, leading to daytime symptoms of impaired function. The prevalence figures are higher in elderly populations and in females. Ohayon in 2002 estimated that based on the DSM-IV classification, the prevalence of diagnosed insomnia is 6% (1). ![]() Insomnia is a common complaint that affects a large proportion of the population at any one time, However, the diagnosis of insomnia as a chronic sleep disorder is also prevalent.
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