Sleep-wake State Discrepancy and Circadian-related Characteristics in Youth with Insomnia

Rachel Ran Wang, Forrest Tin Wai Cheung, Xiao Li, Ngan Yin Chan, Joey Chan, Yun-Kwok Wing, Shirley Xin Li

Abstract

Introduction Individuals with insomnia often perceive their sleep as poorer than objectively measured sleep (e.g., by actigraphy). This phenomenon is known as sleep-wake state discrepancy (SWSD). However, the factors associated with SWSD, particularly among the youth population, are not well understood. Youth represents a distinct developmental period characterized by increased evening preference, irregular sleep-wake pattern and social jetlag, which may potentially influence SWSD. This study aimed to explore the relationship between SWSD and insomnia in youths.

Methods The study included 87 adolescents (mean age: 20.20±2.15, female: 64.1%) meeting the DSM-5 diagnostic criteria for insomnia disorder. Participants completed a 7-day sleep diary and actigraphy assessment for the computation of SWSD indices in total sleep time (TST), sleep onset latency (SOL), and wake after sleep onset (WASO). SWSD indices were calculated by subtracting the data from actigraphy and sleep diary, with a positive value indicating a subjective underestimation. Participants also completed the Munich chronotype questionnaire (MCTQ) and the depression anxiety stress scale (DASS) to assess chronotype and social jetlag and mood symptoms, respectively. Sleep regularity, especially bedtime and rise time variability, was evaluated using 7-day actigraphy-derived intra-individual variability.

Results SWSD-TST was negatively correlated with the MCTQ-derived midpoint of sleep on free-days (MSF) and social jetlag (both p<.01). SWSD-WASO was negatively associated with the MCTQ-derived MSF and midpoint of sleep on workdays (MSW) (p<.01). There was no other significant association among the variables. Controlling for age, sex, depressive and anxiety symptoms, SWSD-TST remained significantly associated with social jetlag (β=-0.39, p<.001) and SWSD-WASO was associated with MCTQ-derived MSW (β=0.34, p<.005).

Conclusion The findings suggested that SWSD in youths with insomnia is linked to late chronotype and greater social jetlag, underscoring the influence of circadian rhythm and sleep regularity on subjective sleep perception. These results highlighted the importance of considering these factors when understanding sleep disturbances in youths with insomnia.

Recommended citation: Wang, R. R., Cheung, F. T. W., Li, X., Chan, N. Y., Chan, J., Wing, Y. K., & Li, S. X. (2025). Sleep-wake State Discrepancy and Circadian-related Characteristics in Youth with Insomnia. Sleep, 48(Supplement_1), A10-A11.