Paradoxical Insomnia in the Presence of Mild Obstructive Sleep Apnea: A Case Report Illustrating Diagnostic Complexity and Treatment Challenges

Paradoxical insomnia (sleep-state misperception) is characterized by a marked discrepancy between self-reported poor sleep and objective polysomnographic evidence of normal sleep duration and architecture. We present a case of paradoxical insomnia comorbid with mild obstructive sleep apnea (OSA), highlighting diagnostic and therapeutic challenges. A 37-year-old woman presented with severe chronic insomnia of eight years' duration, reporting sleeping only "minutes per night," despite appearing alert and functional. A two-night home sleep test showed normal sleep latency (seven minutes), sleep efficiency (86.6%), and total sleep time (4.5 hours). Mild OSA was noted (Apnea-Hypopnea Index (AHI) = 5 events/hour) but was not considered causative of her profound subjective distress. Multiple trials of hypnotics, antidepressants, benzodiazepines, and antipsychotics yielded no subjective improvement. The patient maintained a fixed, delusional-like conviction of sleeplessness despite objective evidence to the contrary, although she lacked other psychotic features. This case underscores the importance of recognizing paradoxical insomnia, particularly when complaints are disproportionate to objective findings and mild comorbid OSA is present. Management should prioritize cognitive behavioral therapy for insomnia (CBT-I) and psychoeducation over pharmacologic escalation. Clinicians should communicate objective sleep data with empathy within a psychoeducational framework to avoid therapeutic rupture and promote engagement in behavioral interventions.