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!

Night Eating and Your Sleep

Holiday weight gain may not be so hard to reverse for people who eat at conventional mealtimes.

Night eaters, though, have trouble taking off weight. Night eating syndrome is a diagnosis given to people who typically consume at least 25% of their daily calories after dinner and/or during nighttime awakenings. It’s also associated with disrupted sleep.

People with night eating syndrome often have disrupted sleepWith the house now full of holiday candy and cookies I know I’m gaining weight. But the time for new year’s resolutions is just around the corner, and my resolve to eat less and exercise more usually lasts long enough to help me shed the extra pounds.

Holiday weight gain may not be difficult to reverse for people who eat at conventional mealtimes.

Night eaters, though, have trouble taking off weight. Night eating syndrome, an eating disorder associated with insomnia, is a diagnosis given to people who typically consume at least 25% of their daily calories after dinner and/or during nighttime awakenings. Here’s more about night eating syndrome, its relationship to sleep, and ways to hold it in check.

Symptoms of Night Eating Syndrome

The main symptoms of night eating syndrome (NES) listed in the Diagnostic and Statistical Manual of Mental Disorders 5th edition are these:

  • recurrent episodes of night eating that take place after dinner or upon awakening from sleep in the middle of the night,
  • awareness of the eating episodes, and
  • significant distress or impairment caused by the nighttime eating.

Other common food-related symptoms of NES are (a) lack of desire to eat breakfast and/or skipping breakfast entirely, (b) cravings for specific foods at night, and (c) satisfaction of the cravings with modest amounts of food.

What NES Is Not

NES is not the same as sleep-related eating disorder, in which a person is unaware of nighttime eating; binge-eating disorder, in which bingeing can occur at any time of day and the amount of food consumed is excessive; or bulimia nervosa, characterized by episodes of bingeing followed by purging.

But people with these eating disorders are more likely to have NES than people without them. NES is also more common in people with depression, anxiety, and other psychiatric conditions than in the general population. It’s more common in people who are obese as well.

A Relationship between NES and Sleep Disturbance

Research has shown that NES is associated with sleep disturbance, say the authors of a review paper published in Neuropsychiatric Disease and Treatment. In some cases, night eating serves as a trigger for insomnia. In other cases, the insomnia precedes development of NES.

Some night eaters have trouble falling asleep at the beginning of the night; others have trouble with nighttime wake-ups. Studies also show that people with NES tend to have low sleep efficiency. In other words, they spend a lot of time lying awake in bed.

Psychological and Biological Factors

Accompanying the behavioral aspects of night eating are related sensations and beliefs. People with NES report feeling

  • anxious and agitated at night,
  • distressed about sleep disruptions, and
  • that they must eat to get to sleep.

Research on NES points to biological underpinnings. The serotonin system—which helps to regulate appetite, eating, and circadian rhythms—may be compromised, impairing satiety, dysregulating circadian rhythms, and disturbing sleep.

Eating disorders investigator Jillon Vander Wal, interviewed by Psychiatry Advisor, said this: “According to the biobehavioral model of NES, an inherited trait or predisposition for NES, when combined with stress, reduces the amount of serotonin in the brain, thereby dysregulating circadian rhythms and decreasing satiety. This model suggests that we can intervene in several ways to reduce the symptoms of this disorder.”

Therapies

Treatments for NES are aimed at decreasing nighttime eating and secondarily at improving mood and facilitating weight loss. Not many controlled studies have been done to assess the efficacy of the various pharmacologic and behavioral options. But here are treatments that have shown potential so far, say the reviewers:

  • SSRI medications, especially sertraline (Zoloft) and escitalopram (Lexapro);
  • medications that facilitate the action of melatonin;
  • progressive muscle relaxation training, alone or combined with patient education and exercise; and
  • cognitive-behavioral therapy (CBT), aimed at helping patients develop healthier habits and attitudes. The main goal of CBT for NES is “to correct the delay in circadian eating rhythms, while simultaneously interrupting the relationship between erroneous cognitions and night eating and sleep.”

If you tend to skip breakfast and eat at night, does your eating pattern affect your sleep? If so, how?

Use Pillows Strategically for Pain-Free Nights

I know from experience that pillows can make a difference between a good night’s sleep and a bad one.

A reader suffering low back pain and insomnia wrote in with a question about pillows a few days ago, prompting me to do a little research. Here’s what I found out.

Insomnia and back pain can be alleviated by placing pillows correctlyThis morning I landed on a blog promoting use of a wooden pillow for intestinal health and insomnia relief. No joke. You’re supposed to lie face down with the “pillow” under your lower stomach and gently shake the abdominal area from side to side. This rocking motion supposedly helps with digestion and spinal alignment, relaxing you and helping you fall asleep.

Pardon my skepticism, but frankly the adjective wooden does not belong in the same sentence as insomnia relief. I’ve blogged about wooden pillows elsewhere and am no more convinced I should place one under my stomach than under my neck!

But I know from experience that pillows can make a difference between a good night’s sleep and a bad one. A reader suffering low back pain and insomnia wrote in with a question about pillows a few days ago, prompting me to do a little research. Here’s what I found out.

Low back Pain and Insomnia

That pain can interfere with sleep is a no-brainer. But there seems to be an especially tight and complex relationship between back pain and insomnia or disturbed sleep. Recent studies from Korea and the United Kingdom suggest that 43 to 47 percent of patients diagnosed with chronic low back pain or chronic back pain also suffer insomnia. A large study conducted in Japan found that low back pain is significantly associated with poor sleep quality and sleeping less than 6 hours a night.

Insomnia also places people at greater risk for the development of low back pain, Israeli researchers found recently. Other investigators have shown that just as low back pain can disturb sleep, so disturbed sleep tends to increase the intensity of pain. This creates a vicious circle: pain disturbs sleep, leading to greater pain, leading to further sleep disturbance, and on and on.

But strategic placement of pillows can alleviate back pain by straightening out the spine and keeping it in alignment, relieving pressure on pain-sensitive areas and creating conditions where you’re more likely to get a decent night’s rest.

Stomach Sleepers

If you like sleeping on your stomach, the pillow supporting your head and neck should be fairly flat. If it’s got too much loft, you wind up sleeping with your neck cranked too far to the side, torquing the upper spine and straining muscles in the neck.

Straighten out the lower spine by sleeping with another fairly flat pillow under your stomach.

Back Sleepers

The pillow supporting your head, neck, and shoulders should be thicker if you prefer sleeping on your back. In its natural position, the human neck curves slightly forward, say doctors writing on spine-health.com. This curve should be maintained during sleep. A too-high or too-low pillow causes muscle strain in the neck. It can also obstruct breathing and result in snoring.

To straighten out the spine in the lower back, take one or more thick pillows and place them under your knees. Flattening out the spine this way relieves pressure on the pain-sensitive joints in the lumbar area.

Side Sleepers

If you prefer to sleep on your side, the pillow supporting your head and neck should be fairly thick. Otherwise the upper spine will be unnaturally bent.

Use of a knee pillow is critical for side sleepers with low back pain. Side sleepers often sleep with bent knees, and without use of a knee pillow, there’s a tendency for the upper leg to fall forward, twisting the lower spine and aggravating lumbar pain. Placing a small, firm pillow between the knees straightens out the spine and will allow for greater comfort and a better night’s rest.

I’m a side sleeper myself, and to avoid low back pain I use a variation of this suggested to me by a physical therapist. Instead of positioning my legs one on top of the other, I pull my top knee forward so it’s at right angles with my torso and place the knee on a small, thick pillow. This helps me sleep through the night and wake up in the morning pain free. Sleeping on the left side in this position is recommended for pregnant women, too.

Pillows flatten out over time and may cease to provide the support you need. My husband teases me about running through pillows likes hotcakes, but expert opinion is on my side. When your pillow loses its loft, it’s time to add stuffing or buy a new one.

Who Says Sleep Declines with Age?

Older adults tend to sleep less than younger adults, with total sleep time declining by about 10 minutes per decade.

But the assumption that sleep problems generally increase with age does not always hold true, according to two studies recently published in the journal Sleep.

sleep-agingI used to be the only insomniac among my champion sleeper peers. Now several of my friends report experiencing insomnia. I guess that’s not surprising: we’re the baby boom generation, and sleep problems tend to increase with age. Or do they?

Older adults do tend to sleep less than younger adults, with total sleep time declining by about 10 minutes per decade. But the assumption that sleep problems generally increase with age does not always hold true, according to two studies recently published in the journal Sleep.

Study Results

Investigators in the first study analyzed complaints of sleep disturbance and tiredness in over 150,000 Americans age 18 and above. What they found was surprising:

  • The youngest group (18- to 24-year-olds) had the highest rate of reported sleep disturbance, and the oldest group (70- to 74-year-old males, and females age 80 and above) had the lowest rate.
  • The 18- to 24-year-olds and adults age 70 and older reported the highest rates of tiredness, while adults age 65 to 69 reporting the lowest rate of tiredness.
  • Overall, the investigators concluded, “both sleep disturbance and tiredness complaints generally declined across the life span.”

In the second study, researchers took data from over 84,000 people in England and Finland and looked to see how sleep lost over worry changed with age. These findings, too, suggest that sleep quality doesn’t necessarily decline with age:

  • Sleep loss over worry was highest among 34- to 55-year-olds.
  • There was a decline in sleep loss over worry between the ages of 56 and 65 (in women, however, the decline began somewhat later than in men).
  • Sleep loss over worry was the lowest in old age.

Sleep Complaints, Health, and Stress

How can we explain why people in the oldest age groups reported better quality sleep than younger people? One factor that may be involved is overall health. People develop more health problems as they age, and many of these problems have a negative impact on sleep and on mortality. People who survive into the oldest age groups may be particularly resilient to age-related health problems and thus may not experience the associated problems with sleep.

Stress is clearly a factor in the sleep loss over worry reported by the younger groups: people in their 20s and 30s are completing college degrees, entering the job market, and bearing and rearing children. Baby boomers well along in middle age are contending with a few stressors too: we’re developing health problems; losing jobs to a younger, cheaper workforce; caring for sick parents; and even parenting grandchildren. Maybe it’s only the luckiest among us that will slide into old age with a clean bill of health and sound, restorative sleep.

Anyway, when I talk about insomnia these days, I’m not the Lonely Hearts Club Band member I used to be. Now I’ve got plenty of company.

If you’ve got a sleep problem, when did it begin? Was it related to stress or something else?

Age and Sleep Disturbances

Sleep Lost over Worry