The direction of sleep state misperception in patients with OSA is specifically associated with multidimensional clinical characteristics, with high AHI independently associated with both positive and negative misperception, while positive and negative misperception directions involve distinct psychopathological and neurocognitive mechanisms.
Key Findings
Methods
Among 700 OSA patients classified by Sleep Perception Index, the majority had normal sleep perception, while meaningful minorities exhibited either positive or negative misperception.
Total sample: 700 patients diagnosed with OSA by polysomnography (PSG) at a sleep center in Jiangsu Province, China, between June 2024 and May 2026
Normal perception group: n = 521
Negative misperception group (underestimating sleep): n = 118
Positive misperception group (overestimating sleep): n = 61
Classification was based on the Sleep Perception Index (SPI)
Results
Higher N3 sleep stage percentage, higher AHI, lower PSQI score, and lower sleep efficiency were independent factors associated with positive misperception in OSA patients.
All four factors reached statistical significance (all p < 0.05) in multinomial logistic regression with the normal perception group as reference
Positive misperception reflects overestimation of sleep (patients believe they slept more than PSG indicates)
Lower PSQI score in this context indicates better self-rated sleep quality
Higher N3% suggests disruptions in objective sleep architecture are linked to positive misperception
Analysis controlled for multiple psychometric and PSG variables simultaneously
Results
Higher AHI, lower SCD-Q9 score, lower DBAS-16 score, lower HADS-Anxiety score, and lower sleep efficiency were independent risk factors associated with negative misperception in OSA patients.
All five factors reached statistical significance (all p < 0.05) in multinomial logistic regression
Negative misperception reflects underestimation of sleep (patients believe they slept less than PSG indicates)
Lower DBAS-16 score indicates more rational (less dysfunctional) sleep-related beliefs were protective against negative misperception
Lower SCD-Q9 score (fewer subjective cognitive decline complaints) was associated with negative misperception
Lower HADS-Anxiety score (less anxiety) was associated with negative misperception
Results
High apnea-hypopnea index (AHI) was independently associated with both positive and negative misperception directions in OSA patients.
AHI appeared as a significant independent factor in both the positive misperception and negative misperception multinomial logistic regression models (all p < 0.05)
This makes AHI the only factor shared between both misperception directions
The finding suggests OSA severity contributes to misperception regardless of direction
The divergence in other associated factors suggests distinct underlying mechanisms for each misperception direction
Discussion
Positive and negative misperception in OSA patients were associated with distinct psychopathological and neurocognitive profiles.
Positive misperception was more closely linked to disruptions in objective sleep architecture (higher N3%) and better self-rated sleep quality (lower PSQI)
Negative misperception involved more rational sleep-related beliefs (lower DBAS-16), more subjective cognitive decline complaints (lower SCD-Q9), and higher anxiety levels (lower HADS-A being protective)
Authors state: 'This divergence suggests that different misperception directions may be related to distinct underlying psychopathological and neurocognitive mechanisms'
The authors conclude this underscores 'the need for precision screening and stratified intervention strategies tailored to the direction of misperception in clinical practice'
Methods
Participants completed multiple validated psychometric instruments on the day of PSG to assess sleep quality, anxiety, depression, dysfunctional beliefs, sleepiness, and cognitive function.
Instruments used: Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale (HADS), Dysfunctional Beliefs and Attitudes about Sleep Scale-16 (DBAS-16), Epworth Sleepiness Scale (ESS), Subjective Cognitive Decline Questionnaire (SCD-Q9), and Montreal Cognitive Assessment (MoCA)
Subjective estimates of the previous night's sleep were collected on the morning after PSG
Sleep Perception Index (SPI) was used to classify patients into three misperception groups
Study design was cross-sectional, limiting causal inference
What This Means
This research suggests that when people with obstructive sleep apnea (OSA) misperceive how much they sleep, the direction of that misperception — whether they think they slept more or less than they actually did — is linked to very different sets of characteristics. The study followed 700 OSA patients in China who underwent overnight sleep monitoring (polysomnography) and completed several questionnaires about their sleep, mood, beliefs about sleep, and cognition. Patients were grouped based on whether their subjective sense of how long they slept matched, exceeded, or fell short of what the sleep test recorded.
This research suggests that people who overestimated their sleep (positive misperception) tended to have more disrupted deep sleep stages, worse OSA severity, and paradoxically rated their own sleep quality as better on questionnaires. In contrast, people who underestimated their sleep (negative misperception, thinking they slept less than they did) were more likely to have less anxiety, fewer complaints about cognitive difficulties in daily life, and more rational beliefs about sleep — suggesting these factors may actually be 'protective' in the sense that their absence increases the chance of underestimating sleep. Notably, high OSA severity (measured by the apnea-hypopnea index) was linked to both types of misperception.
This research suggests that the way OSA patients misperceive their sleep is not a single phenomenon but reflects distinct psychological and neurological processes depending on direction. This matters because OSA frequently co-occurs with insomnia, and understanding why some patients feel they sleep more or less than they actually do could help clinicians identify specific subtypes of patients who may need tailored screening and treatment approaches rather than a one-size-fits-all strategy.
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Jing T, Xu M, Wang Y, Cai Y, Gong Y, Zhu L. (2026). Factors associated with sleep state misperception in patients with obstructive sleep apnea: a cross-sectional study.. Frontiers in neurology. https://doi.org/10.3389/fneur.2026.1925074