New research led by Geneva University Hospitals (HUG), the University of Geneva (UNIGE), and the Universitäre Psychiatrische Dienste Bern (UPD) at the University of Bern (UNIBE) suggests that sleep-wake perception and regulatory systems remain largely intact in people with insomnia disorder.
The findings, published in Scientific Reportsunder the title “Preserved perception of sleep–wake states in patients with insomnia disorder despite altered subjective sleep appraisal”, underscore the value of cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, rather than relying on medication.
Insomnia disorder affects approximately 5 to 10% of adults and is defined primarily by a subjective sense of poor or insufficient sleep—despite often normal results from objective sleep measurements. This disconnect between experience and physiology has posed a challenge for both patients and clinicians.
The study, led by Carlotta Schneider, a PhD student and assistant psychologist at UPD and UNIGE, was conducted in the sleep lab with 30 patients diagnosed with insomnia and 30 healthy participants. Under the supervision of Professor Christoph Nissen—Chief Physician of Psychiatric Specialties and Director of the Sleep Medicine Center (HUG), and Full Professor at the UNIGE Faculty of Medicine—the researchers examined how individuals perceive their sleep during deliberate, repeated awakenings.
After two nights of adaptation and baseline sleep recording, participants were awakened up to 12 times during non-REM (NREM) sleep using vibrating wristbands. During each awakening, an automated interview asked whether they felt they had been asleep or awake. In approximately half of the awakenings, both insomnia patients and healthy participants reported having been asleep, while in the other half, they reported being awake. Perceptions of wakefulness were associated with increased high-frequency brain activity—an indicator of arousal—across both groups.
Although patients with insomnia reported chronic dissatisfaction with their sleep, their objective sleep patterns and real-time sleep-wake perception were not significantly different from those of the healthy control group. These findings align with the emerging concept of a sleep–wake continuum, which challenges the traditional view that sleep and wakefulness are strictly separate states. The results support growing evidence that sleep-wake regulatory systems remain functional in many patients with insomnia and that sleep complaints are often maintained over time by cognitive, emotional, and behavioral mechanisms.
“This research points to a crucial insight,” said the authors. “For many patients, insomnia is not due to a fundamental biological sleep defect but rather to learned patterns and perceptions that can be unlearned or reframed.”
The implications are significant: patients may benefit more from CBT-I, which targets maladaptive thoughts and behaviors around sleep, than from long-term use of sleeping pills. While pharmacological treatments may offer short-term relief, they carry risks of side effects, tolerance, and dependency.
Further studies are underway to explore the sleep–wake continuum in greater detail, identify potential subtypes of insomnia, and expand access to CBT-I.
