Little is known regarding the prevalence of sleep state misperception and the factors related to this in patients with obstructive sleep apnea (OSA).
This retrospective study included patients with OSA defined by an apnea–hypopnea index (AHI) of ≥ 5 and used the Insomnia Severity Index (ISI), the Epworth sleepiness scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7. Underestimation and overestimation of sleep state perception were defined as < 80% and > 120%, respectively, of the ratio between subjective and objective total sleep time. An ISI score > 14 indicated clinically significant insomnia and an AHI ≥ 30 indicated severe OSA. A multinomial logistic regression was conducted with the category of sleep state perception as an outcome variable.
Of the 707 patients with OSA, underestimation and overestimation of sleep state perception were noted in 22.5% and 10.6% of subjects, respectively. The median absolute differences (and percentages of the ratio) between subjective and objective total sleep time were 116 min (66.9%) and 87 min (127.3%) in the underestimated and overestimated perception groups, respectively. In the adjusted model, the underestimated group was more likely to have an ISI score > 14 (OR = 1.812, P = .006). The overestimated group was more likely to be older (OR = 1.025, P = .025) and has severe OSA (OR = 1.729, P = .035).
There are two patterns of sleep state misperception in patients with OSA: underestimation associated with comorbid insomnia symptoms and overestimation associated with severe OSA. These findings enhance understanding of the pathophysiology of sleep state misperception in patients with OSA.
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Rezaie L, Fobian AD, McCall WV, Khazaie H (2018) Paradoxical insomnia and subjective-objective sleep discrepancy: a review. Sleep Med Rev 40:196–202. https://doi.org/10.1016/j.smrv.2018.01.002
(2005) International classification of sleep disorders: diagnostic & coding manual. 2nd edn. American Academy of Sleep Medicine, Westchester
Edinger JD, Krystal AD (2003) Subtyping primary insomnia: is sleep state misperception a distinct clinical entity? Sleep Med Rev 7:203–214. https://doi.org/10.1053/smrv.2002.0253
Mercer JD, Bootzin RR, Lack LC (2002) Insomniacs’ perception of wake instead of sleep. Sleep 25:564–571
Edinger JD, Bonnet MH, Bootzin RR, Doghramji K, Dorsey CM, Espie CA, Jamieson AO, McCall WV, Morin CM, Stepanski EJ, American Academy of Sleep Medicine Work Group (2004) Derivation of research diagnostic criteria for insomnia: report of an American Academy of Sleep Medicine Work Group. Sleep 27:1567–96. https://doi.org/10.1093/sleep/27.8.1567
Kim BS, Jeon HJ, Hong JP, Bae JN, Lee JY, Chang SM, Lee YM, Son J, Cho MJ (2012) DSM-IV psychiatric comorbidity according to symptoms of insomnia: a nationwide sample of Korean adults. Soc Psychiatry Psychiatr Epidemiol 47:2019–2033. https://doi.org/10.1007/s00127-012-0502-0
Luyster FS, Buysse DJ, Strollo PJ Jr (2010) Comorbid insomnia and obstructive sleep apnea: challenges for clinical practice and research. J Clin Sleep Med 6:196–204
Al-Jawder SE, Bahammam AS (2012) Comorbid insomnia in sleep-related breathing disorders: an under-recognized association. Sleep Breath 16:295–304. https://doi.org/10.1007/s11325-011-0513-1
Wickwire EM, Collop NA (2010) Insomnia and sleep-related breathing disorders. Chest 137:1449–1463. https://doi.org/10.1378/chest.09-1485
Bianchi MT, Williams KL, McKinney S, Ellenbogen JM (2013) The subjective-objective mismatch in sleep perception among those with insomnia and sleep apnea. J Sleep Res 22:557–568. https://doi.org/10.1111/jsr.12046
McCall WV, Turpin E, Reboussin D, Edinger JD, Haponik EF (1995) Subjective estimates of sleep differ from polysomnographic measurements in obstructive sleep apnea patients. Sleep 18:646–650. https://doi.org/10.1093/sleep/18.8.646
Pinto LR Jr, Pinto MC, Goulart LI, Truksinas E, Rossi MV, Morin CM, Tufik S (2009) Sleep perception in insomniacs, sleep-disordered breathing patients, and healthy volunteers–an important biologic parameter of sleep. Sleep Med 10:865–868. https://doi.org/10.1016/j.sleep.2008.06.016
Harvey AG, Tang NK (2012) (Mis)perception of sleep in insomnia: a puzzle and a resolution. Psychol Bull 138:77–101. https://doi.org/10.1037/a0025730
Means MK, Edinger JD, Glenn DM, Fins AI (2003) Accuracy of sleep perceptions among insomnia sufferers and normal sleepers. Sleep Med 4:285–296. https://doi.org/10.1016/s1389-9457(03)00057-1
Castillo J, Goparaju B, Bianchi MT (2014) Sleep-wake misperception in sleep apnea patients undergoing diagnostic versus titration polysomnography. J Psychosom Res 76:361–367. https://doi.org/10.1016/j.jpsychores.2014.03.001
Choi SJ, Suh S, Ong J, Joo EY (2016) Sleep misperception in chronic insomnia patients with obstructive sleep apnea syndrome: implications for clinical assessment. J Clin Sleep Med 12:1517–1525. https://doi.org/10.5664/jcsm.6280
Nam H, Lim JS, Kim JS, Lee KJ, Koo DL, Lee C (2016) Sleep perception in obstructive sleep apnea: a study using polysomnography and the multiple sleep latency test. J Clin Neurol 12:230–235. https://doi.org/10.3988/jcn.2016.12.2.230
Berry RB, Brooks R, Gamaldo CE, Harding SM, Marcus C, Vaughn BV (2012) The AASM manual for the scoring of sleep and associated events. Rules, terminology and technical specifications, version 2.0. American Academy of Sleep Medicine, Darien
Cho YW, Lee JH, Son HK, Lee SH, Shin C, Johns MW (2011) The reliability and validity of the Korean version of the Epworth sleepiness scale. Sleep Breath 15:377–384. https://doi.org/10.1007/s11325-010-0343-6
Bastien CH, Vallieres A, Morin CM (2001) Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med 2:297–307. https://doi.org/10.1016/S1389-9457(00)00065-4
Cho YW, Song ML, Morin CM (2014) Validation of a Korean version of the insomnia severity index. J Clin Neurol 10:210–5. https://doi.org/10.3988/jcn.2014.10.3.210
Kroenke K, Spitzer RL, Williams JBW (2001) The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 16:606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Choi HS, Choi JH, Park KH, Joo KJ, Ga H, Ko HJ, Kim SR (2007) Standardization of the Korean Version of Patient Health Questionnaire-9 as a screening instrument for major depressive disorder. J Korean Acad Farm Med 28:114–119
Spitzer RL, Kroenke K, Williams JB, Lowe B (2006) A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 166:1092–7. https://doi.org/10.1001/archinte.166.10.1092
Seo JG, Cho YW, Lee SJ, Lee JJ, Kim JE, Moon HJ et al (2014) Validation of the generalized anxiety disorder-7 in people with epilepsy: a MEPSY study. Epilepsy Behav 35:59–63. https://doi.org/10.1016/j.yebeh.2014.04.005
Olaithe M, Bucks RS, Hillman DR, Eastwood PR (2018) Cognitive deficits in obstructive sleep apnea: insights from a meta-review and comparison with deficits observed in COPD, insomnia, and sleep deprivation. Sleep Med Rev 38:39–49. https://doi.org/10.1016/j.smrv.2017.03.005
Mathieu A, Mazza S, Petit D, Décary A, Massicotte-Marquez J, Malo J, Montplaisir J (2007) Does age worsen EEG slowing and attention deficits in obstructive sleep apnea syndrome? Clin Neurophysiol 118:1538–1544. https://doi.org/10.1016/j.clinph.2007.04.009
Morisson F, Lavigne G, Petit D, Nielsen T, Malo J, Montplaisir J (1998) Spectral analysis of wakefulness and REM sleep EEG in patients with sleep apnoea syndrome. Eur Respir J 11:1135–1140. https://doi.org/10.1183/09031936.98.11051135
Buysse DJ, Germain A, Hall M, Monk TH, Nofzinger EA (2011) A neurobiological model of insomnia. Drug Discov Today Dis Models 8:129–137. https://doi.org/10.1016/j.ddmod.2011.07.002
Harper RM, Kumar R, Macey PM, Ogren JA, Richardson HL (2012) Functional neuroanatomy and sleep-disordered breathing: implications for autonomic regulation. Anat Rec (Hoboken) 295:1385–1395. https://doi.org/10.1002/ar.22514
Páramo-Brando AM, Durán P, Del Río-Portilla IY, Poblano A, Haro R (2020) Differences in electroencephalographic spectra during pre-sleep wakefulness, N1, and R sleep between comorbid insomnia and obstructive sleep apnea. Sleep Breath 24:267–275. https://doi.org/10.1007/s11325-019-01951-y
Moon HJ, Song ML, Cho YW (2015) Clinical Characteristics of Primary Insomniacs with Sleep-State Misperception. J Clin Neurol 11:358–363. https://doi.org/10.3988/jcn.2015.11.4.358
Tsuchiyama K, Nagayama H, Kudo K, Kojima K, Yamada K (2003) Discrepancy between subjective and objective sleep in patients with depression. Psychiatry Clin Neurosci 57:259–264. https://doi.org/10.1046/j.1440-1819.2003.01114.x
Vgontzas AN, Fernandez-Mendoza J, Liao D, Bixler EO (2013) Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder. Sleep Med Rev 17:241–254. https://doi.org/10.1016/j.smrv.2012.09.005
Matthews KA, Patel SR, Pantesco EJ, Buysse DJ, Kamarck TW, Lee L, Hall MH (2018) Similarities and differences in estimates of sleep duration by polysomnography, actigraphy, diary, and self-reported habitual sleep in a community sample. Sleep Health 4:96–103. https://doi.org/10.1016/j.sleh.2017.10.011
Ng MC, Bianchi MT (2014) Sleep misperception in persons with epilepsy. Epilepsy Behav 36:9–11. https://doi.org/10.1016/j.yebeh.2014.04.007
Hirsch M, Carlander B, Vergé M, Tafti M, Anaya JM, Billiard M, Sany J (1994) Objective and subjective sleep disturbances in patients with rheumatoid arthritis. A reappraisal. Arthritis Rheum 37:41–49. https://doi.org/10.1002/art.1780370107
Bian Y, Wang ZX, Han XL, Chen L, Zhu Y, Wu CJ (2016) Sleep state misperception in schizophrenia: are negative symptoms at work? Compr Psychiatry 67:33–38. https://doi.org/10.1016/j.comppsych.2016.02.008
This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Asan Medical Center approved this study.
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Lee, SA., Im, K. & Yang, Hr. Factors associated with sleep state misperception in patients with obstructive sleep apnea. Sleep Breath 26, 1921–1930 (2022). https://doi.org/10.1007/s11325-021-02543-5
- Obstructive sleep apnea
- Sleep state misperception
- Sleep apnea severity