Paradoxical as a Sleep State and Disorder

Paradoxical sleep is a lay term for the rapid eye movement (REM) phase of sleep. It applies to a sleep state, an experience of insomnia characterized by sleep state misperception, and even a behavioral treatment for insomnia. Get the facts on this stage of sleep and the sleep disorder known as paradoxical insomnia. Also, learn how paradoxical intention works to treat insomnia.

Woman sleeping in her bed
Ray Kachatorian / Getty Images

What Defines Paradoxical Sleep?

Also known as REM sleep or dreaming sleep, paradoxical sleep is a distinct stage of sleep with intense brain activity in the forebrain and midbrain.It is characterized by dreaming and the absence of motor function with the exception of the eye muscles and the diaphragm. It occurs cyclically several times during sleep and predominates towards morning, but it often comprises the smallest portion of the sleep cycle.

During paradoxical sleep, our muscles are relaxed so that we don't act out our dreams. If this fails, REM sleep behavior disorder can develop.

The paradox is that even though the brain is quite active during REM sleep, consuming large amounts of energy, the body remains completely inactive.

What Is Paradoxical Insomnia?

Insomnia is defined as difficulty falling asleep and it is often exacerbated by sleep-related effort. Paradoxical insomnia is a rare condition in which people misjudge how long it takes for them to fall asleep as well as how long they have actually slept. They may think they have only been asleep for a couple of hours, even if they have slept for seven or eight. People with this disorder are extremely aware of their surroundings while sleeping, suggesting that they may transition often between light, stage 1 sleep, and wakefulness.

The next day they feel sleep deprived. Melatonin, over-the-counter medications containing diphenhydramine, and prescription-strength sleep drugs (such as Ambien or Lunesta) can counter the symptoms of paradoxical insomnia.

Paradoxical insomnia is considered to be rare because while insomnia affects roughly 30 percent of the global population, fewer than five percent of these cases are deemed paradoxical.

In typical cases of insomnia, if you try to fall asleep, it won't happen. But what if you try to stay awake? The use of a behavioral technique called paradoxical intention sleep therapy may help.

Behavioral Changes Can Improve Insomnia

There are a variety of behavioral interventions that can be effective in treating chronic insomnia. These are collectively employed as part of a structured program called cognitive behavioral therapy for insomnia (CBTI). Some of these changes rely on altering how you think about or perceive a situation, the component known as cognitive therapy. One such option is paradoxical intention.

What Is Paradoxical Intention?

A paradox is defined as a statement that may seem superficially absurd or self-contradictory, but when it is investigated or explained may prove to be well-founded or true. One such paradox in insomnia is that by staying up later, you might actually fall asleep faster and sleep better. It is possible to use effort surrounding your sleep, which often perpetuates insomnia, paradoxically to your advantage.

Paradoxical intention is a form of cognitive therapy in which you learn to confront the fear of staying awake and the potential adverse effects. It may be learned from a psychologist, psychiatrist, or a physician trained in sleep medicine. Paradoxical intention helps to relieve the "performance anxiety" of falling asleep.

As part of this, you might objectively evaluate the consequences of a poor night of sleep on daytime function. This cognitive restructuring may relieve some of the anxiety about getting to sleep promptly at night. In addition, you can actually try to stay awake in order to fall asleep faster.

How Does Paradoxical Intention Treat Insomnia?

Rather than attempting to force yourself to sleep—in a sense, to perform on-demand—you instead remain passively awake without any effort to fall asleep. With training, you stop "trying" to sleep (which never works). Quiet wakefulness becomes an acceptable alternative. Cognitive distraction, including breathing techniques, progressive muscle relaxation, and guided imagery, may also prove to be helpful.

Paradoxical intention can be achieved by staying awake until you feel sleepy and then going to bed. Retire to the bedroom and turn out the lights and preserve the sleep environment as a place conducive to rest and sleep (without activities such as reading, watching TV, or excessive light or noise). Lie quietly with your eyes closed. Instead of focusing on getting to sleep, try to stay awake. Surprisingly, you may find that you fall asleep faster in these conditions.

The anxiety of not being able to sleep is thus gradually relieved as you learn to accept quiet wakefulness as an acceptable alternative when you are in bed.

Paradoxical intention may be particularly helpful in people who have insomnia that is characterized by a difficulty falling asleep at the start of the night. It has been demonstrated to be effective and has no risks of side effects.

The Use of Paradoxical in Sleep Medicine

So, the adjective paradoxical may be used in three distinct ways in reference to topics in sleep medicine. It described a state of sleep that is better known as REM sleep. It refers to a type of insomnia in which sleep is misinterpreted as wakefulness. Finally, it is a useful behavioral technique in which the intention paradoxically becomes an effort to stay awake, rather than to fall asleep. No matter how it is used, understanding sleep can be enhanced by defining these sorts of terms.

A Word From Verywell

If you need additional assistance with your insomnia, find a CBTI specialist in your area and finally put an end to your insomnia. It may also help to have an evaluation by a board-certified sleep medicine physician who can arrange further testing and treatment.

13 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Rezaie L, Fobian AD, McCall WV, Khazaie H. Paradoxical insomnia and subjective–objective sleep discrepancy: A review. Sleep Medicine Reviews. 2018;40:196-202. doi: 10.1016/j.smrv.2018.01.002

  2. Hong CCH, Fallon JH, Friston KJ, Harris JC. Rapid eye movements in sleep furnish a unique probe into consciousness. Front Psychol. 2018;9:2087. doi: 10.3389/fpsyg.2018.02087

  3. Eunice Kennedy Shriver National Institute of Child Health and Human Development. What happends during sleep?

  4. Roguski A, Rayment D, Whone AL, Jones MW, Rolinski M. A neurologist’s guide to rem sleep behavior disorder. Front Neurol. 2020;11:610.

  5. U.S. National Library of Medicine. Insomina.

  6. American Family Physician. Paradoxical Insomina: Misperception of Sleep Can Be a Tormenting Experience.

  7. Wasey W, Saleh S, Abernathy K, Sapra A, Bhandari P. Paradoxical insomnia in a frustrated patient treated with hypnotics for ten years. Cureus. doi: 10.7759/cureus.16234

  8. Sharma M, Andrade C. Behavioral interventions for insomnia: Theory and practice. Indian J Psychiatry. 2012;54(4):359. doi: 10.4103/0019-5545.104825

  9. Trauer JM, Qian MY, Doyle JS, Rajaratnam SMW, Cunnington D. Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(3):191-204. doi: 10.7326/M14-2841

  10. Jansson‐Fröjmark M, Alfonsson S, Bohman B, Rozental A, Norell‐Clarke A. Paradoxical intention for insomnia: A systematic review and meta‐analysis. Journal of Sleep Research. 2022;31(2). doi: 10.1111/jsr.13464

  11. Jerath R, Beveridge C, Barnes VA. Self-regulation of breathing as an adjunctive treatment of insomnia. Front Psychiatry. 2019;0. doi: 10.3389/fpsyt.2018.00780

  12. Liu K, Chen Y, Wu D, Lin R, Wang Z, Pan L. Effects of progressive muscle relaxation on anxiety and sleep quality in patients with COVID-19. Complementary Therapies in Clinical Practice. 2020;39:101132. doi: 10.1016/j.ctcp.2020.101132

  13. Jerath R, Beveridge C, Jensen M, Paladiya R. The therapeutic role of guided mental imagery in treating stress and insomnia: a neuropsychological perspective. OJMP. 2020;09(01):21-39. doi: 10.4236/ojmp.2020.91003

Additional Reading
  • Kryger, MH et al. "Principles and Practice of Sleep Medicine." Elsevier, 6th edition, 2017.

By Brandon Peters, MD
Brandon Peters, MD, is a board-certified neurologist and sleep medicine specialist.