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Factors associated with sleep state misperception in patients with obstructive sleep apnea



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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Authors and Affiliations



Conceptualization: Sang-Ahm Lee. Methodology: Sang-Ahm Lee. Writing-original draft preparation: Sang-Ahm Lee. Reviewing and editing, Supervision: Sang-Ahm Lee. Data curation: Kayeong Im, Ha-rin Yang. Formal analysis: Sang-Ahm Lee.

Corresponding author

Correspondence to Sang-Ahm Lee.

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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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This was a retrospective study based on records, and formal consent was not required.

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The authors declare no competing interests.

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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).

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  • Obstructive sleep apnea
  • Sleep state misperception
  • Insomnia
  • Sleep apnea severity
  • Underestimation
  • Overestimation