Insomnia: How Do You Score?

You may know you’ve got insomnia. But could you prove it?

Researchers use pencil-and-paper tests to assess different aspects of sleep: sleep quality, insomnia severity, sleep reactivity, and sleep-related beliefs. If you’re unfamiliar with these questionnaires, you may find it interesting to look at them and see how you score.

How do you score on tests given to people with insomniaYou may know you’ve got insomnia. But could you prove it?

There is no lab test for insomnia that would back you up.

An overnight sleep study, then?

Maybe—but probably not. Sleep studies don’t discriminate very well between insomniacs and good sleepers.

Genetic factors?

There may be genetic markers associated with insomnia, but researchers have no definitive understanding of what they are or how they add up to insomnia. The diagnosis of insomnia disorder is still made subjectively, based on questions and answers about sleep.

The list of questions doctors often ask to make the determination is fairly short and sweet.  But researchers use pencil-and-paper tests to assess different aspects of sleep: sleep quality, insomnia severity, sleep reactivity, and sleep-related beliefs. If you’re unfamiliar with these questionnaires, you may find it interesting to look at them and see how you score.

At the Doctor’s Office

If you take your complaints about sleep to the doctor, he or she may attempt to rule out other disorders before asking questions related to insomnia. You’ll get a diagnosis of insomnia disorder if

  • you have trouble falling or staying asleep, or sleep that doesn’t feel restorative, at least 3 times a week,
  • your sleep problem has persisted for at least 3 months, and
  • you experience impairment(s) during the daytime: moodiness, for example, or trouble concentrating or a lack of stamina that interferes with social, occupational, and other types of functioning.

Researchers, however, use pencil-and-paper assessment tools to evaluate subjects’ sleep and sleep improvements. Following are some of these questionnaires, downloadable as PDF files.

Pittsburgh Sleep Quality Index (PSQI)

In 1989 University of Pittsburgh sleep scientists introduced the PSQI in an attempt to quantify an aspect of sleep acknowledged to be important but difficult to measure.

The scoring of the PSQI questionnaire—with 19 self-rated questions—is a bit involved, but explicit scoring instructions are given at the end of the test. (Five more questions are to be answered by your bed partner or roommate if you have one. But these questions are not scored.) The 19 self-rated questions are divided into 7 “component” scores. The component scores are then added together to get the global score, which can range from 0 to 21. A global score of over 5 is indicative of poor sleep quality.

Sample question: During the past month, how often have you had trouble sleeping because you wake up in the middle of the night or early morning?

Insomnia Severity Index (ISI)

Some people experience insomnia occasionally while others experience it practically every night. The severity of a person’s insomnia may predict how likely he or she is to respond to various treatments. So it’s seen as a key variable to take into account when diagnosing insomnia and recommending a treatment, and when assessing improvements in study participants’ sleep.

Scores on this 7-item ISI questionnaire range from 0 to 28. Trouble sleeping is considered to be severe enough to warrant a diagnosis of insomnia disorder if scores are 8 or higher.

Sample question: How worried/distressed are you about your current sleep problem?

Ford Insomnia Response to Stress Test (FIRST)

The FIRST is the newest of the tests, introduced in 2004. This questionnaire is said to measure people’s overall level of “sleep reactivity,” a trait hypothesized to increase the likelihood of a person’s sleep being disturbed during stressful situations. The claim is that people who score higher on the FIRST are more likely to develop persistent insomnia.

FIRST scores range from 9 to 36. Scores of 20 and above indicate that stressful situations experienced prior to sleep—or the anticipation of stressful situations ahead—may routinely knock your sleep off track and make you vulnerable to chronic insomnia. Access this questionnaire by looking at Table 1 on the third page of this article about stress-related sleep disturbance.

Sample questions: How likely is it for you to have difficulty sleeping (a) after an argument? (b) before having to speak in public?

Dysfunctional Beliefs and Attitudes About Sleep Scale (DBAS)

If you don’t sleep well, you may find yourself having negative thoughts about sleep. Over time, these thoughts may coalesce into ideas, attitudes, and beliefs about sleep that give rise physiological arousal, making it harder TO sleep. In turn, the sensations of increased warmth, muscle tension, and faster heart rate that accompany arousal reinforce the negative thoughts, giving rise to a vicious circle.

The 16-item DBAS identifies misconceptions about sleep and assesses how big a role these and other cognitive factors likely play in perpetuating a person’s insomnia. A high score suggests that dysfunctional beliefs and attitudes may be a significant component of your insomnia, amenable to treatment with cognitive therapies.

Sample item: When I sleep poorly on one night, I know it will disturb my sleep schedule for the whole week.

If you’re curious enough to take any of these tests and end up learning something about your sleep, please take a moment to share it by leaving a comment. Thanks!

Stress-Related Insomnia? Don’t Give Up

Why does stress cause insomnia in some people while other people can park their stress outside the bedroom door? No one has a comprehensive answer to this question.

But researchers say that sleep reactivity, situational factors, and responses to stress determine who’s likely to develop insomnia and who isn’t. Here’s more about the research and how to keep stress from ruining the night.

Stress affects some people's sleep more than others, but everyone can become more resilientWhy does stress cause insomnia in some people while other people can park their stress outside the bedroom door? No one has a comprehensive answer to this question; too many things are involved.

But researchers at Henry Ford Hospital say that—in addition to sleep reactivity, a trait-level quality that predisposes some of us to insomnia—situational factors and responses to stress determine who’s likely to develop insomnia and who isn’t. Here’s more about their research on stress and sleep and thoughts about how to keep stress from ruining the night.

How Investigators Got Their Information

The study they conducted was aimed at identifying factors that cause sleep to go from good to bad. They used data collected from good sleepers participating in the Evolution of Pathways to Insomnia Cohort study.

First, the researchers determined that none of the 2,892 participants qualified for an insomnia diagnosis at the beginning of the study. Next, participants took several pencil-and-paper tests designed to assess relationships between stress and sleep. A year later, the group took the same battery of tests a second time to ascertain how their lives and their sleep had changed.

Impact of Stress on Sleep

By the end of the year, 262 study participants, or 9.1%, had developed insomnia disorder.* The number, severity, and duration of stressors had a significant impact on participants’ sleep. The odds of developing insomnia increased

  • by 19% for every additional stressor participants reported
  • by 4% for every one-point increase participants gave to stressors on a severity scale
  • by 2% for every 1-month increase in the duration of stress.

None of this is surprising, but it’s interesting to see quantitative data coming out of a prospective study.

Response to Stress

Many insomniacs say that what keeps them awake is a mind that keeps going and going at night. In this study, participants had to report how much they thought about the stress they were experiencing by assigning a numerical value to statements like this: “I thought about it when I didn’t mean to.”

The tendency to engage in intrusive thinking following stress exposure was a significant predictor of who would and wouldn’t develop insomnia, accounting for 69% of the total effect of stress exposure on insomnia. The inclination to ruminate has long been known to perpetuate insomnia. The results of this study suggest that rumination may also precipitate insomnia.

Coping Strategies Matter, Too

But vulnerability to insomnia isn’t just a matter of genes and traits and happenstance. How we cope with stress can also amplify or mitigate its effects on sleep. The authors note that thought suppression, a strategy insomniacs often use to hold intrusive thoughts at bay, usually backfires. It tends not to empty the mind but rather to heighten cognitive arousal.

They also report that under conditions of stress, the following coping strategies are predictors of insomnia:

  • substance use
  • giving up based on a belief that nothing can be done to ease the situation
  • self-distraction

But regarding self-distraction (which I believe actually helps me when I’m feeling too aroused for sleep), the authors acknowledge that the literature on this coping style is mixed. Some studies suggest it’s effective in times of stress and others suggest it’s of little or no benefit.

So What to Do?

What not to do is pretty clear from the above. Better strategies for managing stress (and its negative effects on your sleep) are these:

  1. Make sure you have a physical outlet for your stress: daily exercise, or a mind-body practice such as yoga, qi gong, and tai chi.
  2. Try mindful stress reduction. Early studies suggest that it helps reduce stress.
  3. Resist the urge to go it alone. Research has shown that spending time with friends and supportive family members reduces stress.
  4. Increase predictability where you can. If sporadic late night phone calls from your mother stress you out, ask her to refrain from calling after 7 p.m.
  5. Do what you can to increase your sense of control (except in extreme situations where you really have no control). Shorten your to-do list by getting rid of nonessential commitments; negotiate for someone else to cook the turkey this year; and when a stressor feels overwhelming, sit down with a paper and pencil and break the problem into smaller parts. This way, you can actively work to ease or resolve the situation in a step-by-step fashion, which will likely help your sleep.

When you’re stressed out, do you find that distraction helps or hurts your sleep?

* Insomnia disorder was defined in this study as (a) trouble falling or staying asleep, or nonrefreshing sleep, at least 3 times a week for at least 1 month, and (b) daytime distress or impairment.

It Might Not Be Insomnia After All

People come here looking for solutions to sleep problems. Some read about sleep restriction, a drug-free insomnia treatment, and decide to try it on their own. It’s not rocket science: insomnia sufferers who follow the guidelines often improve their sleep. It’s empowering to succeed.

But self-treatment is not the right approach for everyone. Sometimes insomnia is complicated by another disorder, or what looks like insomnia is actually something else. In both cases, the best thing to do is to have yourself evaluated by a sleep specialist ASAP.

Self-help treatments for insomnia will not work for other sleep disordersI’m a take-charge person when it comes to managing chronic health problems, especially when solutions proposed by doctors are unsatisfactory. I hunt for solutions myself, reading a lot and sometimes coming up with a fix.

People come to my blog looking for solutions to their sleep problems. Some read about sleep restriction, a drug-free insomnia treatment, and decide to try it on their own. It’s not rocket science: insomnia sufferers who follow the guidelines often improve their sleep. It’s empowering to succeed.

But self-treatment is not the right approach for everyone. Sometimes insomnia is complicated by another disorder, or what looks like insomnia is actually something else. In both cases, the best thing to do is to have yourself evaluated by a sleep specialist ASAP.

Up Late at Night

Chris wrote in with questions about sleep restriction several months ago:

I recently started sleep restriction therapy about 3 days ago, and I’m not too tired during the day even though I barely slept the last two nights. Is this normal? I set my bed time at 3:30 a.m. and force myself to get up at 9:30 a.m. even if I haven’t slept too well. Should I restrict my time even more if I’m not too tired? Additionally, I find that I have anxiety when I am in bed sometimes. Do you think I should get out of bed if I am anxious?

Chris knows he experiences insomnia, but the symptoms he reports aren’t the classic symptoms of people with insomnia disorder.

  • He’s “not too tired during the day” even though he “barely slept the last two nights”; many insomniacs during the first week of sleep restriction report feeling tired and out of sorts.
  • He’s set his sleep window at 3:30 to 9:30; a more normal sleep window would be from 12 to 6. Maybe Chris works the evening shift and can’t get to bed until 3:30. But if this is his sleep window of choice, then maybe he has a circadian rhythm disorder—in which case sleep restriction would not be an appropriate treatment.
  • He’s anxious when he’s awake in bed; many insomniacs are, too. But Chris’s anxiety could also be an indication of something else.

Chris’s situation sounds complicated and as though in starting sleep restriction he may be on the wrong track. My response to Chris and others like him is to suggest seeing a sleep specialist for an accurate diagnosis and guidance in managing the problem.

Sleepy in the Afternoon

Shelley contacted me via Ask The Savvy Insomniac. “Could sleep restriction help me?” was the subject line of her email.

I’ve had insomnia for 5 years now. Getting to sleep is no problem. But I wake up several times at night. It’s a drag. The alarm rings in the morning and it never feels like the night was long enough. I manage OK in the morning but after lunch I’m like the walking dead. Coffee doesn’t help. I fall asleep during meetings all the time and people notice. It’s embarrassing.

Nighttime wake-ups are a common symptom of chronic insomnia. But Shelley’s inability to stay awake during afternoon meetings gives pause.

It might seem logical that a person with insomnia would feel sleepy during the daytime, and some insomniacs report that they do. Other words that describe the feeling are tired, fatigued, and exhausted.

But the actual inclination to nod off involuntarily during the daytime is not as common in people with insomnia as it is in people with other sleep problems: sleep apnea, for example, and narcolepsy. It might sound counterintuitive, but a majority of insomniacs given opportunities to sleep during the day are no more likely to do so, say sleep experts, than people who sleep well at night. In fact, some studies show it takes insomniacs longer than normal sleepers to fall asleep during the daytime.

If Shelley has sleep apnea or narcolepsy, sleep restriction will do more harm than good. She needs to consult a sleep specialist and get a diagnosis before starting any type of treatment.

The Take-Away

What looks like insomnia may not actually be insomnia disorder. Before you plunge into sleep restriction or any other insomnia treatment, see a doctor for a diagnosis or do lots of reading to make sure that what you’ve got is insomnia and not something else.