Neurobiological mechanisms of sleep state misperception in insomnia disorder: A theoretical review

Sleep state misperception is core to pathophysiological models of insomnia, suggesting that it arises from a dysfunction in neurobiological mechanisms which result in sleep being misperceived as wake. The current review aims to synthesise the best available literature on the neurobiological mechanisms of sleep state misperception and the extent to which the existing literature supports this theory. Overall, findings suggest that cognitive and neurophysiological hyperarousal and dysfunctional sensory-gating mechanisms that insufficiently inhibit arousal may largely account for the phenomenon of sleep state misperception observed among patients with paradoxical insomnia. Most studies to date, however, have relied on comparing self-reports of sleep duration with polysomnography-derived sleep duration, limiting our ability to differentiate the effects of perception from retrospective-reporting bias. Therefore, more studies which use contemporaneous assessments of sleep-wake perception are required to directly test the hypothesis that subjective-objective discrepancies arise from altered perception of sleep states. We report here a research agenda to promote the further development of research in the field and propose several key empirical questions which remain to be explored.