研究目的：失眠患者常出現對睡眠的主觀知覺與客觀測量結果不一致的現象，其中以高估入睡耗時及低估睡眠時長最為常見，此一現象稱爲「睡眠錯誤知覺 (sleep misperception)」；近年則逐漸以較中性的「主客觀睡眠差異 (subjective-objective sleep discrepancy, SOSD)」加以描述。過去研究認為，SOSD 可能與過度激發、睡眠相關認知偏誤、覺醒調控異常，以及個體對內在生理訊號之覺察與詮釋歷程有關。然而，過去研究比較侷限於單一的向度探討，對於 SOSD 之基本特性、形成機制及其治療改變歷程的瞭解相當有限。本論文透過三個研究分別探討：(一) SOSD 之基本特性及其相關因素；(二) 探討 SOSD 與主客觀壓力反應差異之關聯性，以檢驗個體對內在生理訊號之感知與詮釋歷程在SOSD 形成中的可能角色；以及 (三) 心理及行為介入對 SOSD 之影響及其改變機制，以期建立較完整之 SOSD 理論架構。
研究方法：研究一納入102位失眠患者，透過一夜多項睡眠生理記錄 (polysomnography, PSG)、連續七個晚上的腕動式活動記錄儀，以及七日睡眠日誌蒐集主客觀睡眠資料，並結合睡眠脆弱性、睡前激發、睡眠信念、焦慮及憂鬱等量表，探討SOSD之特性及相關因素；同時使用階層線性模式 (hierarchical linear modeling, HLM) 分析每日睡眠品質與白天功能在個體間及個體內的變異對SOSD之影響。研究二納入73位失眠患者，透過經壓力誘發作業，測量其對壓力誘發及壓力解除後的主觀壓力評估與測量心率、呼吸速率、膚電，及指溫的生理反應，探討主客觀壓力反應差異與SOSD之關聯。研究三則納入63位失眠患者，以隨機分派到三組，分別接受失眠認知行為治療 (cognitive behavioral therapy for insomnia, 簡稱CBT-I)、CBT-I結合心率變異生理回饋訓練，或CBT-I結合正念訓練，以比較不同介入策略對 SOSD 的改變效果，並探討失眠相關心理機制變項的改變與SOSD變化之關聯。
研究結果：研究一結果顯示，不同客觀測量方式所得之 SOSD 具有中高度相關，顯示SOSD 可跨客觀睡眠測量方式下被穩定觀察。然多夜分析發現，SOSD 同時具有個體內每日的波動與個體間穩定差異，且個體內變異占比較高，顯示其兼具狀態性與特質性特徵。此外，不同睡眠向度之 SOSD 與不同心理變項呈現不同的關聯性，其中焦慮相關之身體症狀與 SOSD 之關聯最爲穩定，HLM 分析則顯示隔日白天嗜睡程度較高，前一晚入睡耗時之 SOSD 較低。研究二結果顯示，SOSD 與主客觀壓力反應差異之間存在特定對應關係，其中睡眠時長的 SOSD 主要與心跳速率之主客觀壓力差異有關，而入睡耗時與夜間清醒時間的 SOSD 則較與呼吸速率之主客觀壓力差異有關，顯示睡眠知覺與內在生理訊號的覺察可能部分具有共通的機制。研究三結果顯示，三種 CBT-I 介入皆能有效改善失眠症狀及相關心理機制，但僅總睡眠時長的 SOSD 於治療後呈現顯著改變，不同治療組別間並未呈現顯著差異。此外，SOSD 之改變未必與失眠症狀改善同步，而較與睡眠信念、失眠脆弱性與正念態度有關。
結論：綜合本論文三項研究結果顯示，SOSD 並非單純的睡眠估計誤差，也不完全反映失眠症狀嚴重度，而是一種兼具穩定性與動態性的睡眠知覺現象。研究一顯示 SOSD 具有跨測量工具的一致性及個體內動態變化，而對於焦慮或壓力的身體反應，與 SOSD 最具相關性。研究二也進一步支持壓力相關反應的內在覺感及身體訊號處理在 SOSD 形成中的重要角色。而研究三進一步顯示部分SOSD 可透過心理介入而改變，但其改變機制未必等同於失眠改善歷程，反而與信念、正念態度等認知的向度較爲有關。基於上述結果，本論文對所提出之「SOSD 形成歷程之整合概念架構」提供了不同層面的支持。SOSD會隨白天嗜睡等情境因素呈現動態變化，並與激發、情緒、對內在生理訊號的感知與處理，以及睡眠信念等內在因素呈現特定關聯，顯示睡眠知覺可能是多重訊息共同作用下所形成的結果。據此架構，主觀睡眠知覺可能建立於睡眠相關生理現象之上，透過訊息處理、注意力分配、內在覺感，以及認知評價及經驗詮釋的歷程所建構而成。此外，不同睡眠指標之 SOSD 呈現不同的相關因素與改變的模式，顯示其可能反映不同層面的睡眠知覺歷程。整體而言，本論文重新詮釋了 SOSD 的本質，提出整合性的理論架構，為未來探討睡眠知覺及 SOSD 的機制，以及失眠的評估與介入提供新的方向與架構。

Introduction：Patients with insomnia often exhibit discrepancies between their subjective perceptions of sleep and objectively measured sleep parameters. The most common manifestations include overestimation of sleep onset latency and underestimation of total sleep time. This phenomenon has traditionally been referred to as sleep misperception and, more recently, has been described using the more neutral term subjective–objective sleep discrepancy (SOSD). Previous studies have suggested that SOSD may be associated with hyperarousal, sleep-related cognitive biases, abnormalities in arousal regulation, and the processes through which individuals perceive and interpret internal physiological signals. However, existing research has primarily focused on isolated dimensions of SOSD, leaving its fundamental characteristics, underlying mechanisms, and treatment-related changes insufficiently understood. Therefore, the present dissertation consisted of three studies designed to investigate: (1) the characteristics and correlates of SOSD; (2) the association between SOSD and subjective–objective discrepancies in stress responses, with a particular focus on the potential role of the perception and interpretation of internal physiological signals in the formation of SOSD; and (3) the effects of psychological and behavioral interventions on SOSD and their potential mechanisms of change, with the aim of establishing a more comprehensive theoretical framework of SOSD.
Methods：Study 1 included 102 patients with insomnia. Subjective and objective sleep data were collected using one night of polysomnography (PSG), seven consecutive nights of actigraphy, and seven-day sleep diaries. Measures of sleep reactivity, pre-sleep arousal, dysfunctional sleep beliefs, anxiety, and depression were also administered to examine the characteristics and correlates of SOSD. Hierarchical linear modeling (HLM) was further employed to investigate the effects of both between-person and within-person variations in daily sleep quality and daytime functioning on SOSD. Study 2 recruited 73 patients with insomnia who completed a laboratory-based stress induction task. Subjective stress ratings and physiological responses, including heart rate, respiratory rate, skin conductance, and finger temperature, were assessed during stress induction and recovery phases. The associations between subjective–objective discrepancies in stress responses and SOSD were subsequently examined. Study 3 enrolled 63 patients with insomnia who were randomly assigned using block randomization to one of three intervention conditions: cognitive behavioral therapy for insomnia (CBT-I), CBT-I combined with heart rate variability biofeedback training, or CBT-I combined with mindfulness training. Changes in SOSD across interventions were compared, and the relationships between changes in insomnia-related psychological mechanisms and changes in SOSD were explored.
Results：Study 1 demonstrated moderate to strong correlations in SOSD across different objective sleep measurement methods, indicating that SOSD can be consistently observed across different objective sleep measurement methods. Multi-night analyses further revealed that SOSD contained both stable between-person differences and substantial within-person day-to-day fluctuations, with within-person variability accounting for a larger proportion of the variance. These findings suggest that SOSD possesses both trait-like and state-like characteristics. Moreover, different dimensions of SOSD were associated with distinct psychological variables, among which anxiety-related somatic symptoms showed the most consistent associations. HLM analyses further indicated that greater next-day daytime sleepiness was associated with reduced SOSD in sleep onset latency on the preceding night.
Study 2 revealed specific associations between SOSD and subjective–objective discrepancies in stress responses. In particular, discrepancies in total sleep time was primarily associated with subjective–objective discrepancies in heart rate responses, whereas discrepancies in sleep onset latency and wake after sleep onset were more closely related to discrepancies in respiratory responses. These findings suggest that sleep perception and the perception of internal physiological signals may share common underlying mechanisms. Study 3 showed that all three CBT-I–based interventions significantly improved insomnia symptoms and related psychological mechanisms. However, only total sleep time SOSD showed a significant treatment-related change. No significant differences in treatment effects were observed among the three intervention groups. Furthermore, changes in SOSD were not necessarily accompanied by improvements in insomnia symptoms; instead, different patterns of associations emerged across treatment groups, involving dysfunctional sleep beliefs, sleep reactivity, and mindfulness-related attitudes.
Conclusions：Taken together, the findings of the three studies suggest that SOSD is not merely a simple error in sleep estimation nor solely a reflection of insomnia severity. Rather, it represents a sleep perception phenomenon characterized by both stability and dynamic variability. Study 1 demonstrated the cross-method consistency of SOSD and its substantial within-person fluctuations, while also identifying associations between SOSD and physiological manifestations of anxiety and stress. Study 2 further provided indirect support for the potential involvement of the perception and processing of internal physiological signals in the formation of SOSD. Study 3 showed that some dimensions of SOSD can be modified through psychological interventions, although the mechanisms underlying these changes may differ from those responsible for improvements in insomnia symptoms and may instead be more closely related to cognitive factors such as sleep-related beliefs and mindfulness. Based on these findings, this dissertation provides empirical support for the proposed Integrative Conceptual Framework for the Formation of Subjective–Objective Sleep Discrepancy (SOSD). SOSD showed dynamic variations associated with contextual factors such as daytime sleepiness and specific associations with internal factors, including arousal, emotion, the perception and processing of internal physiological signals, and sleep-related beliefs. These findings suggest that sleep perception may emerge from the joint contribution of multiple sources of information. Within this framework, subjective sleep perception is conceptualized as being grounded in sleep-related physiological processes and constructed through information processing, attentional allocation, interoception, cognitive evaluation, and experiential interpretation. Furthermore, different dimensions of SOSD exhibited distinct correlates and patterns of change, suggesting that they may represent different aspects of the sleep perception process. Overall, this dissertation provides a reconceptualization of SOSD and proposes an integrative theoretical framework that offers new directions for understanding sleep perception, investigating the mechanisms underlying SOSD, and improving the assessment and treatment of insomnia.

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