Factors associated with sleep state misperception in patients with obstructive sleep apnea: a cross-sectional study

This study aimed to investigate factors associated with sleep state misperception (SSM) in patients with obstructive sleep apnea (OSA), and to provide evidence for the early identification and intervention of comorbid insomnia and obstructive sleep apnea (COMISA).

This cross-sectional study enrolled 700 patients diagnosed with OSA by polysomnography (PSG) at a sleep center of a hospital in Jiangsu Province, China, between June 2024 and May 2026. Based on the Sleep Perception Index (SPI), patients were classified into three groups: a negative misperception group (n = 118), a normal perception group (n = 521), and a positive misperception group (n = 61). On the day of PSG, participants completed the 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). On the morning after PSG, subjective estimates of the previous night's sleep were collected. Factors associated with sleep state misperception were identified using multinomial logistic regression analysis.

In the multinomial logistic regression analysis with the normal perception group as the reference, higher N3 sleep stage percentage (N3%), higher apnea-hypopnea index (AHI), lower PSQI score, and lower sleep efficiency (SE) were independent factors associated with positive misperception (all p < 0.05). Higher AHI, lower SCD-Q9 score, lower DBAS-16 score, lower HADS-Anxiety (HADS-A) score, and lower SE were independent risk factors associated with negative misperception (all p < 0.05).

The direction of sleep state misperception in patients with OSA is specifically associated with multidimensional clinical characteristics. High AHI was independently associated with both positive and negative misperception. Positive misperception was more closely linked to disruptions in objective sleep architecture and to better self-rated sleep quality, whereas protective factors against negative misperception involved more rational sleep-related beliefs, more subjective cognitive decline complaints, and higher levels of anxiety. This divergence suggests that different misperception directions may be related to distinct underlying psychopathological and neurocognitive mechanisms, underscoring the need for precision screening and stratified intervention strategies tailored to the direction of misperception in clinical practice.