Sleep Medicine Reviews (2004) 8, 177–198

www.elsevier.com/locate/smrv

CLINICAL REVIEW

Self-report measures of insomnia in adults:

rationales, choices, and needs
Douglas E. Moul*, Martica Hall, Paul A. Pilkonis, Daniel J. Buysse

Department of Psychiatry, Western Psychiatric Institute and Clinic, Sleep and Chronobiology Center,
University of Pittsburgh, Room E-1119, 3811 O’Hara Street, Pittsburgh, PA 15213, USA

KEYWORDS Summary Self-report measures continue to provide key information in the evaluation
Insomnia; Methodology; and treatment of insomnia. While knowledge development about insomnia continues
Questionnaires; to require multi-trait, multi-method studies, self-report measures remain central in
Literature review; most study designs. The available stock of insomnia-related questionnaires has a
Adults; Priorities; substantial heterogeneity in their formats, foci, scopes, and other attributes. While
Criteria there may be benefits from using specially tailored questionnaires in particular
circumstances, in other cases the information quality of a study will be downgraded by
poor choice of questionnaires. To assist clinicians and investigators in selecting
questionnaires wisely, the present paper reviews questionnaire criteria and attribute
priorities for clinical trials, theory tests, observational studies, and aging studies
concerning insomnia. An extensive table of currently available questionnaires is
provided, and some needs for future questionnaire development are also identified.
q 2003 Elsevier Ltd. All rights reserved.

Insomnia has become a topic of increasing interest
as more becomes known about the impact of
insomnia on psychological functioning and physical
health. Many kinds of studies are important for
researching insomnia, and many kinds of self-report
instruments will be needed to investigate it fully.
The selection of instrument(s) for a particular study
depends partly upon the definition of insomnia an
investigator selects. Kleitman made the point that
‘hyposomnia’ might be a better term to describe
the problem that most people experience. In the
historical past, ‘insomnia’ denoted any poor sleep-
ing (including sleep apnea). However, insomnia now
has more constrained definitions, all without well-
defined polysomnographic (PSG) criteria. 1
*Corresponding author. Tel.: þ1-412-624-5281; fax: þ1-412-
624-2841.
E-mail address: moulde@upmc.edu (D.E. Moul).
The International Classification of Sleep Disorders
(ICSD) defines mild insomnia as ‘an almost nightly
complaint of an insufficient amount of sleep or not
feeling rested after the habitual sleep episode’2
The American Psychiatric Association’s Diagnostic
and Statistical Manual (DSM) defines Primary
Insomnia as ‘a complaint of difficulty initiating or
maintaining sleep or of non-restorative sleep that
lasts for at least 1 month,’ along with the presence
of functional impairment or significant distress.3
These differing definitions reflect the lack of
consensus in defining insomnia as a syndrome. As
a symptom, insomnia is also understood to be
integral to well-defined medical conditions (e.g.
depression, pain, head trauma) that, when present,
disqualify an experienced insomnia as being psy-
chophysiologic or primary. Stated differently, the
general construct validity of insomnia as a clinical
problem is generally acknowledged, yet as a specific

1087-0792/$ - see front matter q 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S1087-0792(03)00060-1
178
syndrome, its construct validity remains proble-
matic. Both the ICSD and DSM definitions refer to
insomnia as a collection of symptoms (i.e. com-
plaints) rather than as a collection of clinical signs.
Broadly speaking, insomnia research makes use
of various approaches in attempting to understand
the causes and consequences of poor sleeping. Self-
report questionnaires have remained a mainstay of
insomnia research for several reasons. First, self-
reports remain the primary metric for clinicians
who treat insomnia patients. Second, obtaining
self-reports is comparatively inexpensive. Third, in
the absence of biomarkers of insomnia, and in the
presence of competing definitions of insomnia, self-
report questionnaires provide key data through
which one study may be compared to another. In
contrast to many other syndromes, unique meth-
odological problems may arise when studying
insomnia because some of the subjective and
objective data represent the same phenomena
(e.g. sleep latency). The resulting subjective –
objective contrasts may challenge the validity of
self-reports of sleep beyond the usual difficulty of
establishing the semantic validity of self-reports.4,5
The clinical definition of chronic insomnia
probably cannot be based only on self-reports or
only on PSG or other objective measures of
sleeping. For this reason, it is highly important to
be conceptually precise about the relation of self-
reports to PSG data. A clear reference point is that
the validity of PSG data cannot be regarded as an
absolute, monolithic measure of sleep. PSG leads
(e.g. C4) report on only a small fraction of the
brain’s activity during sleep, and illuminate little
about brain activity during waking to correlate with
daytime symptoms of insomnia. Self-reports remain
a part of any syndromal definition of chronic
insomnia, and because of this also have validity,
albeit a validity different from that of PSG data.
While self-reports have this generalized validity, a
separate question asks what relation exists
between self-reports having different periods of
recall (e.g. past-night versus past-week). At first
glance, this relation between recall periods appears
to concern validity, or truthfulness, in reporting.
However, because self-reporting is inherently
experiential rather than strictly ‘factual’, it is
clear that these relations are merely phenomen-
ological rather than subject to strict tests of
contradiction. (Interestingly, the same might be
said for comparisons between objective measures.
For example, it would make no sense to say that
PSG data from the C4 lead was the ‘objective’
measure of sleep state, whereas the data from the
F3 lead was not valid because it may not be in strict
D.E. Moul et al.
synchrony with the C4 lead or present the same
data.)
Self-report data and PSG data can certainly be
examined for their validity in relation to one
another where they concern the same phenomena,
for example, sleep latency. However, self-report
data may report on sleep-related phenomena that
are currently impossible to measure objectively
with current technologies. In any case, conceptual
difficulties persist regarding what is actually being
measured in current measurement systems. While
this conceptual difficulty inhibits confidence in
current theories about insomnia, it also means
that there still are many opportunities for research-
ing how candidate objective and subjective
measures are related to one another. By impli-
cation, these difficulties indicate the need for
multi-trait, multi-method programs of research
using various measures associated with subjective
and objective poor sleeping. For example, a trait
such as a person’s habitual sleep latency may be
researched with multiple methods of objective and
subjective measurement. Similarly, various traits
(e.g. sleep latency, number of awakenings, sleep
efficiency) may be investigated with cross-correla-
tional methods. In the future, new traits to study
may be identified, and new methods of measure-
ment may be developed.
Self-report measures are not the sole data for
studying insomnia, and should be correlated with
data derived from the PSG and other physiological
measures. On the other hand, even if biomarkers of
chronic insomnia become well established, self-
report data will remain a vital source of infor-
mation. Just as with any other syndrome in clinical
medicine, a complete explanation of chronic
insomnia will require precise and detailed concep-
tual linkages between objective physiological
abnormalities in insomnia patients and patients’
symptoms, as expressed in self-reports.
To assist researchers in selecting instruments,
this paper has the following aims: (1) To review
some criteria by which insomnia self-report instru-
ments may be evaluated, (2) to prioritize different
criteria for different classes of insomnia research,
(3) to review current insomnia-related self-report
instruments, and (4) to identify self-report instru-
ments that are needed.
Measurement domains and criteria
Testing self-report instruments psychometrically is
important because the average research subject
might provide imprecise or biased responses in
Self-report measures of insomnia in adults: rationales, choices, and needs 179

Table 1 Priorities for characteristics in various study types.

Domain Characteristics Study type

Clinical Theory Epidemiological Genetics Services Economic

trials test cross-section research

Scaling and scoring Continuous measurement scaling A A B C B A

Transparency of scoring A B B C A C
Item-response characteristics B A B C B B
Symptoms and impacts Nighttime and daytime symptoms A B A B B C
Cognitive domains B A C C B C
Functional impairment and quality A C A C A A
of life

Time and prediction Short time-frame for self-report B A A B B B

Treatment responsivity A B C C A A
Predictive validity C A B B A A
Sensitivity and specificity Sensitivity for caseness C C B C A A
Specificity for caseness C C A A B B
Positive predictive value C C A C A A
Instrument burden Brevity of instrument B C A C A B
Low costs C B A C A A
Theories and causes Construct validity C A C C B C
Measures potential confounders B A A A B B
Measures causal intermediates C A C B B C
Aspects of care Ease of implementation C C A C A A
Linkages to service use C C B C A A
Acceptability to end users C C B B A B
Costs and utility Direct cost estimates of care A C A C A A
Indirect cost estimates of syndrome C C A C A A
Utility assessments A C C C A A

A: high priority; B: intermediate priority; C: low priority.

relation to a questionnaire’s measurement objec-
tives. These problematic responses impair accurate
scaling of the latent dimensions (e.g. sleep quality,
usual sleep length, sleepiness) that the instrument
proposes to measure. Several authors discuss gen-
eral methods of assessing instruments.6,7 In
addition, assessment of an instrument’s feasibility,
theory relevance, and other qualities is also import-
ant. Furthermore, when variables or instruments
have different scopes of reference (e.g. particular
symptom versus quality of life), how variables relate
to one another becomes an analytic problem.8 Table
1 presents an assessment of priorities for selected
general measurement domains and criteria within
several research contexts.
Pro and Con: making your own
instrument, or using an established one
Why not just make up ad hoc questions for one’s
study, as needed? In some cases this is a good
strategy, particularly if one is venturing into a new
and unique area. Pioneers of new areas need to
invent new questions and instruments, since new
topics require new measures. Designing one’s own
instrument gives one flexibility. However, when
similar studies already exist, overuse of study-
specific measures generally lowers the scientific
value of a particular study, and of studies in
general. An example illustrates what happened
over time in a collection of studies conducted
without standardized instruments.
A review of randomized, double-blind studies of
longer-term hypnotic use in patients with chronic
insomnia shows that they used a wide variety of
study-specific measures. However, several stub-
born problems present themselves when one wants
to generalize across these studies. First, subjects
were diagnosed using the different definitions and
procedures. This makes comparisons between
studies difficult, and impairs the extrapolation of
findings to other research or clinical settings.
Second, the measures of outcome were
not uniform. Where one investigator chose
self-reported sleep latency as a critical variable,9
180
another chose self-reported quality of life.10 So for
the question of long-term effectiveness of hypno-
tics, the overuse of study-specific measures has
contributed to uncertainties about prescribing
hypnotics.
Why not only use well-validated, ‘brand-name’
instruments? This may be a good strategy as
well, depending on the circumstances. Validating
questionnaires requires psychometric testing that
includes test – retest reliability and validity (i.e.
‘truth value’) assessments. Concurrent validity in
relation to insomnia refers to how the instrument
correlates to other existing measures of phenomena
related to chronic insomnia. For example, how
related is the instrument to PSG measures of sleep,
or to other self-report measures of fatigue? In
addition, discriminant validity testing asks if differ-
ent samples of subjects (e.g. insomnia vs.
depressed) provide different questionnaire
responses. Completing such psychometric studies
is specialized and time-consuming. Thus, using a
validated, study-appropriate instrument only
upgrades a study’s scientific value. A researcher is
wise to stipulate a study’s specific measurement
objectives carefully and to decide if an available
instrument meets those objectives.
Before discussing the role that the study aims
have in guiding instrument selection, a few general
criteria for instrument selection are worth noting.
First, is the instrument at the correct reading level
for the study sample? Second, does the instrument
use words that local subjects normally use to refer
to subjective states? For example, a questionnaire
in Spanish written in Spain may not be suitable for
use in Mexico. Third, does the instrument use words
largely free of double meanings? For insomnia
patients, a particularly difficult word here is
‘sleepiness,’ which different patients use variously
to refer to an actual tendency to fall asleep, to
lowered levels of alertness, or to increased feelings
of somatic fatigue. Empirical tests of a words’
semantics in the target population may be required
before it can be used in a questionnaire. Finally, is
there a reasonable correspondence between the
sample in which the instrument’s psychometrics
were studied and the sample in the particular study?
Study aims: some general types
A specific study’s research design might fit into one
of several general categories that occur commonly
and that share rationales for instrument selection.
Several considerations can be reviewed when
selecting instruments for a particular study. First,
D.E. Moul et al.
what general kind of research question is being
asked, considering the study’s specific aims?
Second, given the general kind of question, what
are the usual measurement priorities for this study
type? Third, what are the practical constraints of
using a particular instrument? Lastly, will one or
more established instruments suffice, will some
need to be modified, or will a new instrument need
to be invented? We review several general situ-
ations by way of illustration, asking these four
questions in turn. We will avoid review of instru-
ments with time frames of one-day (e.g. diaries) or
‘now’ (e.g. self-reports at time of awakening)
reporting (reviewed by Spielman et al.11), and
focus more on instruments with a week-to-week
time frame.
Scenario 1: efficacy studies
One common study design tests the efficacy of a
particular hypnotic medication or defined beha-
vioral intervention, compared to another medi-
cation, another intervention, or placebo.
What is the general kind of question that is
asked in efficacy studies for insomnia? The general
question is whether one can detect a statistically
significant difference in one or more defined out-
come variables between comparable samples of
subjects ideally differing only by the specific
medication or intervention to which they were
exposed. Often there are accompanying investi-
gations about the safety and side-effects of
medication(s).
What are the measurement priorities in efficacy
studies for insomnia? The attributes of highest
importance are those of treatment responsivity,
relative temporal precision, continuous measure-
ment scaling, and transparency of scoring, in
addition to broad symptom coverage and overall
summary scoring.
If the goal of the study is to find differences
between treatments, one needs to employ a
measure that produces timely and precise numeri-
cal changes as soon as the subject experiences
symptomatic improvement in target symptoms.
However, the time frame of reporting should be
considered in relation to the study question. A
weekly time frame of self-report questionnaires is a
critical external validity issue for studies that
investigate the stability and/or safety of longitudi-
nal interventions because that comparison is made
to clinical contexts where only weekly visits are
usually possible. ‘Now’ reporting enhances internal
validity because the self-reporting time frame is
Self-report measures of insomnia in adults: rationales, choices, and needs
more immediate, but it does not reflect how the
week-by-week and longitudinal effectiveness of
interventions are usually assessed by clinicians.
‘Now’ self-reports are not more or less valid than
weekly self-reports (unless the respondents are
consciously lying) because these time frames of
reporting exist in a phenomenological, and not a
validity, relationship to one another, in the absence
of an ‘objectively’ subjective standard. (The
debate about long-term hypnotic use has been ill-
served by studies using questionnaires and labora-
tory-based studies that facilitate only high internal
validity.)
Breadth of coverage and overall summary scoring
protects the study against individual differences in
symptoms or in their semantic descriptions. Trans-
parent scoring rules ensure that the data obtained
will be conceptually and statistically unambiguous.
Attributes of medium priority are scoring of
symptom subdomains and quality of life. Subdomain
and quality of life attributes help localize where the
therapeutic benefits occur. Attributes of low
priority for efficacy studies include trait measure-
ment, high diagnostic specificity, and theory
relevance. These last attributes are more appro-
priate for questions about diagnosis, mechanisms of
disease, or mechanisms of action, none of which are
the primary focus of efficacy studies.
A special caution is worth noting about symptoms
in efficacy studies. If a medication has side-effects
that resemble the one or more symptoms of
insomnia (e.g. mild sleepiness, fatigue), then
their inclusion as items in the outcome measure
will reduce the chances of demonstrating a treat-
ment effect.
What practical constraints should be weighed in
selecting an instrument for an efficacy study? One
major consideration is whether the data collection
process may be too burdensome for the subjects so
that they drop out from the study. Too many
dropouts degrades a study’s ease and quality of
analysis, creates potential non-response biases,
and decreases the overall likelihood of demonstrat-
ing a treatment effect. If the instrument needed is
actually an interview conducted by properly trained
clinical interviewers, then the cost of employing,
training, and supervising these interviewers can be
high. In some circumstances, data collection may
be possible only using interviews or related
methods.
Will one or more instruments suffice to answer
the general outcome question across medication
efficacy studies, or is there a need for better
instruments? Several instruments have been used
successfully in aiding investigators to establish the
efficacy of treatments for insomnia. The Leeds
181
Sleep Evaluation Questionnaire (LSEQ),12 con-
structed for use in medication trials, has been
useful in documenting clinical change. Morin’s
Insomnia Severity Index (ISI)13 has been used
successfully in conjunction with comparisons of
medication versus cognitive-behavioral treatments
of insomnia. Spielman’s Insomnia Symptom Ques-
tionnaire (SISQ),14 a set of visual analogue scales,
has been used quite successfully in documenting
treatment efficacy. The recently described Athens
Insomnia Scale (AIS)15 attempts to integrate day-
time with nighttime perceptions in one metric, but
awaits use in a clinical trial. The Pittsburgh Sleep
Quality Index (PSQI)16 has robust psychometric
characteristics related to general sleep quality
and is widely applicable in adult populations. It
has been used in several efficacy trials. Hoelscher’s
Insomnia Impact Scale (IIS)17 covers a broad range
of subjective distress and cognitive items in a
uniform Likert-scale format, and has been used in
outcome studies. Jenkins’ Sleep Problems Ques-
tionnaire (SPQ)18 asks for the number of nights/days
with four kinds of sleep difficulties in the last
month. To our knowledge, the SPQ has not been
used in efficacy trials. The ISI, SISQ, AIS, PSQI, SPQ
are brief. The Quality of Life in Insomnia (QOLI)
scale19 might also be considered in efficacy trials
where broader outcomes are considered. The ISI
has been translated into French. The PSQI and QOLI
have been more widely translated.
All these questionnaires appear to have at least
some psychometric validity, but have limitations as
efficacy measures. The current best questionnaires
for week-to-week assessments probably are the
LSEQ, ISI and SISQ. The LSEQ asks about both
nighttime and morning domains, but does not
include subjective sleep parameters, uses the
reference to ‘usual’ experience, and is designed
for use in medication rather than behavioral trials.
The ISI and SISQ focus mostly on daytime symptoms.
The AIS attempts to integrate daytime with night-
time perceptions, but does not attempt to obtain
subjective sleep parameters. The PSQI does inte-
grate nocturnal and daytime assessments that
include parameters, but uses a one-month recall
period and complicated scoring rules. The SPQ is
short, but without items reflecting subjective
distress. The IIS focuses more on subjective
distress, but has a 2-week reporting period. The
QOLI does not query subjective sleep parameters,
and contains 51 wordy items in differing response
formats. Yet the QOLI is preferred where quality of
life in relation to insomnia is the main focus. The
popular SF-3620 is suboptimal in insomnia popu-
lations because some of its quality-of-life questions
(e.g. ‘Does your health now limit you in…lifting or
182
carrying groceries?’) relate poorly to the health
concerns of insomnia patients.
At the present time there is no established
instrument best suited to broad-based efficacy
evaluations in clinical trials. Recently, our group
has begun testing the Pittsburgh Insomnia Rating
Scale (PIRS)21 which we hope will meet this need.
Many questionnaires, including the PIRS, have been
designed to instrument symptoms, rather than to
obtain endorsements of improvements. To our
knowledge, no instrument is available with psycho-
metrics for use in this ‘positive’ sense, although the
LSEQ asks about comparisons to ‘usual.’ Several
limited attempts at designing questionnaires in the
positive style can be found among insomnia efficacy
studies.
Scenario #2: testing a theory-based
intervention
Several behavioral and psychological interventions
are available for helping insomnia patients. These
include sleep hygiene interventions, relaxation
training, stimulus control, sleep restriction, and
cognitive therapy. Studies have documented the
efficacy of each of these interventions with the
exception of sleep hygiene. From a medical point of
view, these interventions must, on principle, be
related to physiological improvements in the sleep
of insomnia patients. Medical theories explaining
the physiological mechanisms of action of beha-
vioral interventions require studies to actually test
the theories underlying these interventions. Paral-
lel requirements are also present for theories about
the mechanism(s) of action of pharmacological
interventions, yet those theories do not rely as
much upon self-report data for verification.
What is the general kind of question that is
asked in studies of theory-based interventions for
insomnia? These studies ask the general question of
how the sequence of intermediate outcomes occur
during the intervention to produce the therapeutic
outcome. A related and more discriminating kind of
question is whether the therapeutic change occurs
more in accordance with one or another particular
mechanistic theory of action.
All mechanistic theories about interventions must
provide time-series predictions that explain the
explicit order in which various phenomena occur
during the therapeutic transformation. At the end of
the transforming time series, all theories must
provide the linkage of neural phenomena back to
the self-reportable states that underpin patients’
symptom reports. By providing such an account, such
D.E. Moul et al.
a theory about insomnia therapy explains how an
intervention improves sleep onset, maintenance, or
quality. These process theories concern antecedents,
intermediate outcomes or effects, and final thera-
peutic outcomes. For example, in theories explaining
how hypnotic medications work, some intermediate
effects normally cited are those of the medications on
neuronal receptors and ion channels in the chain of
events that result in patients going to sleep. In
theories explaining how physical interventions (e.g.
sleep restriction, hot baths) work, some temporally
prior outcomes concern the physiological effects of
the physical exposures on intermediate brain
phenomena in the path to sleep induction. In the
case of medication-based or physical interventions,
this linkage is normally given in a theoretical account
derived from pre-clinical neuroscience (e.g. regard-
ing how hypnotics work chemically). Where such
neuroscience is unavailable, the theoretical linkage is
drawn through a time series of phenomenal data,
with the theory stipulating what phenomena occur
first, second, etc., in explicit sequence. Since the
neuroscience of behavioral interventions for insom-
nia is still unavailable, behavioral theories can now
only be properly tested in relation to whether they
accurately stipulate the sequence of phenomena
occurring in the therapeutic process along the path to
the final therapeutic outcome(s).
What are the measurement priorities in theory-
based interventions for insomnia? For theories
explaining the mechanism of action of hypnotics
or physical interventions, self-report instruments
are largely irrelevant as measures of intermediate
effects or outcomes, even while such instruments
are necessary as measures of final therapeutic
outcomes. For example, the explanation of a
hypnotic’s chemical effects on neurons relies in no
way on any self-report. The same cannot be claimed
for behavioral or psychological theories. For the
later kinds of theories, the characteristics of the
self-report instruments used to measure intermedi-
ate effects in a causal series becomes critical
because it is such data that are needed to
substantiate whether the particular theoretical
mechanism occurs as postulated. With theory-
testing studies, the study goal is not so much to
advance knowledge of effects as it is to advance
knowledge of causes.
The highest priority attributes in such circum-
stances are treatment responsivity, construct
validity, theory-relevant process measurement,
and high temporal precision. Here, theories
stipulate two main requirements: particular latent
variables and temporal sequences. The instru-
ment(s) should have theory-driven construct val-
idity for those latent variables that change during
Self-report measures of insomnia in adults: rationales, choices, and needs
the therapeutic intervention(s). For example, if a
theory postulates that insomnia patients are
cognitive worriers, then the selected instru-
ment(s) should quantify cognitive worrying faith-
fully in relation the postulated theory in order
that the study may substantiate the theory.
Theory-postulated intermediate states should be
well instrumented with high (even instantaneous)
temporal precision in order to test whether
therapeutic processes are accurately predicted
by the theory. For example, if a theory states that
dysfunctional cognitions mediate between the
intention to sleep and sleep itself, then some
instruments are required to measure such cogni-
tive events in exact temporal series. In this case,
it would be highly important to select a self-
report instrument with a short recall period, and
frankly wrong to select a self-report instrument
with a long recall period. If the instrument(s)
cannot place intermediate events exactly in the
postulated event series, then the study design
cannot comment on whether the theory is true,
false, or misattuned.
Medium-priority attributes for theory-testing
studies are continuous measurement scaling, speci-
ficity, and trait measurement. These attributes can
be important, depending on the circumstances.
Continuous measurement scaling may be critical for
statistical power considerations. If the theory is
specific to one kind of insomnia, then specificity in
that sense may be rather important. Likewise, trait
measurement may be important for identifying those
psychological types for whom the theory is especially
descriptive. Lower priority attributes are wide
symptom domain, quality of life measurement,
transparency of scoring, or transportability to usual
clinical settings. These last attributes are generally
unimportant because the design tests a theory, not a
final outcome or ordinary clinical feasibility.
What practical constraints should be weighed in
selecting an instrument for a theory-testing study?
An instrument’s everyday practicality is not
important for a theory-testing study. Testing a
theory usually requires ‘laboratory-grade’ con-
ditions with high internal validity, where the
sample and therapeutic exposures are very care-
fully characterized. Using less than ‘laboratory-
grade’ measurements actually contradicts the
underlying research aim. It is a sad calamity
when a theory-based study lacks the design quality
to test the postulated theory because of poor
instrument selection: No new knowledge becomes
available. For theory-based studies, investigators
are wise to select subjects willing to complete
exhaustively all the therapeutic interventions and
measurement activities. Such selection will create
183
sampling biases, yet the presence of sampling
biases is only a secondary consideration in theory-
testing studies.
Will one or more instruments suffice to answer
theory-testing question across studies, or is there a
need for better self-report instruments? Several
established questionnaires can be productively
used for some theories and some purposes. Since
many theories are relevant in insomnia research,
Table 2 provides a listing of questionnaires that
investigators have used to address theories in
relation to insomnia. In constructing this table,
we refrained from providing reliability and validity
data because we believe it is the responsibility of
individual investigators to ascertain whether par-
ticular instruments have reliability and validity in
their own samples and research contexts.
On general review, many of the questionnaires
address process theories only indirectly, or rep-
resent outcomes rather than precursors. For
example, the SII was constructed with a conception
that dysfunctional cognitions are an important
interference in the sleep of insomnia patients.
This seems intuitively correct. Yet the SII does not
have the temporal resolution necessary to confirm
or disconfirm this clinical theory. Instead, its
questions are more focused at a dispositional (e.g.
‘Are you now the kind of person who…’) time-scale.
In the past, the Minnesota Multiphasic Personality
Inventory was used in this way, too, but with
variable results. Helpful theories have been con-
structed at dispositional levels of time-scale, yet it
is not clear how to use such research predictively in
clinical or psychophysiological laboratory settings
because dispositional notions are probabilistic
rather than deterministic in their predictive
capacity. Furthermore, if the sleep patterns of
insomniacs behave chaotically in the mathematical
sense, then currently available questionnaires are
poorly suited to elucidating causal processes in
insomniac patients.
If a study focuses on a theory’s generalizability in
new populations, then using a theory’s standar-
dized instrument is rather mandatory. A good
example of a theory-based measure is Morin’s use
of the SII and related instruments22 that track the
cognitive aspects of insomnia patients. Morin’s own
therapy-optimizing studies focus on patients with
primary insomnia. However, if one wanted to know
whether the same theory also applied to bipolar
disorder patients with insomnia, then using the SII
would be clearly important. On the other hand, if an
investigator has a new intervention based on a new
theory, then using a well-standardized instrument
simply because it is well known may not properly
test the new theory. Investigators need to use or
184 D.E. Moul et al.

Table 2 Selected conceptual frameworks in insomnia research and related questionnaires.

Conceptual Questionnaire Time-frame Commentsb

frameworka

Sleep
Sleep Diagnostic questionnaires are desirable;
evaluation however, the validity of these questionnaires to
final diagnoses is not established
Sleep Disorders Indefinite One hundred and seventy-five five-point scale
Questionnaire37 items; directed at diagnosis. Subscalesc for
sleep apnea, periodic limb movement disorder,
narcolepsy, and psychiatric sleep disorder
Sleep questionnaire and Indefinite Eight hundred and sixty-three mixed-format
assessment of wakefulness38 items; directed at exhaustive survey of causes
and consequences of sleep problems of all types
Basic nordic sleep Past 3 Twenty-one mixed-format items. Domains of
questionnaire (PNSQ)39 months sleep patterns, insomnia symptoms, snoring,
excessive sleepiness
Dutch sleep disorders Indefinite One hundred and seventy-six five-point scale
questionnaire40 items; directed at diagnosis. Domains of
healthy, depression, narcolepsy, and apnea
Lacks’ sleep history Indefinite Forty-eight mixed-format items; designed to
questionnaire41 focus diagnostic questioning in a structure sleep
history interview
Post-sleep ‘Now’ instruments have the greatest intuitive
evaluation appeal for ‘accurate’ reports, but their
relationships to reports from other time frames
needs clearer description. These instruments
focus on the past night
VSH sleep scale42 Today Eight VAS (Visual Analogue Scale) items for
hospital patients. Domains of fragmentation,
length, delay, and depth
Sleep and signs and symptoms Today Eleven mixed-format check-box items for
questionnaire43 medication studies. Domains of sleep
parameters, sleep quality, awakening quality,
medication effectiveness, and dream
disturbance, with additional clinician-rated
side-effect items
The post-sleep inventory44 Today Thirty thirteen-point-scale items. Domains of
‘going to bed,’ ‘during the night,’ and ‘on
awakening.’ Factors of mental activity,
morning factors, sleep factors, evening/night
ailments, dream amount, sleepiness in evening,
and dream emotion
Wolff’s morning questions45 Today Eight Yes/No items. Reports on
medication/pillow use, bedpartner presence,
sleep onset difficulty, awakenings, sleep length,
morning restedness
St. Mary’s hospital sleep Today Fourteen mixed-format items, many with
questionnaire46 checkboxes. Reports on sleep parameters,
sleep quality, awakenings, sleep onset
difficulty, morning alertness. Available in
French47
Kryger’s subjective Today Nine mixed-format items. Reports on sleep
measurements48 parameters, sleep quality, sleep onset
difficulty, awakening quality
Morning sleep questionnaire49 Today Four mixed-format items: sleep onset difficulty,
sleep length, sleep depth, and sleep goodness
Subjective evaluation of Today Six VAS and three sleep parameter items.
sleep50 Domains of various specific sleep qualities and
morning restedness
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Self-report measures of insomnia in adults: rationales, choices, and needs
Table 2 (continued)
Conceptual Questionnaire
frameworka
Schlaffregebogen A (SF-A)51
Sleep quality
Pittsburgh sleep quality
index16
Sleep questionnaire52
Sleep disturbance
questionnaire53
Schlaffregebogen B (SF-B)51
Sleep onset
Nocturnal sleep onset scale
(NSOS)54
Generic
outcomes
Spielman insomnia symptom
questionnaire (SISQ)14
Athens insomnia scale (AIS)55
Pittsburgh insomnia rating
scale (PIRS)21
Leeds sleep evaluation
questionnaire (LSEQ)57
Epidemiology
185
Time-frame Commentsb
Today Twenty-three mixed-format items written in
German. Domains of sleep quality, post-sleep
evaluation, evening psychological composure,
evening psychological exhaustion, and somatic
symptoms in sleep
‘Sleep quality’ is a term of art. Yet there
remains a need to assess poor sleeping and its
consequences in a comprehensive fashion
Past month Nineteen mixed-format items and five
roommate-rated items. Algorithm for global
score from components of sleep quality, sleep
latency, sleep duration, habitual sleep
efficiency, sleep disturbance, use of sleeping
medication, daytime functioning. Available in
numerous languages
Indefinite Fifty-nine mostly five-point-scale items;
Eighteen scales derived. Factors of sleep depth,
difficulties waking, sleep latency, negative
affect/dreams, sleep length, dream
recall/vividness, sleep irregularity. Some scales
(e.g. masculine/feminine) go beyond themes in
other scales
Indefinite Twelve five-point-scale items. Factors of
‘mental anxiety,’ ‘stress problem pattern,’ and
‘physical tension’
Past 2 weeks Twenty-nine mixed-format items written in
German. Factors of sleep quality, post-sleep
evaluation, evening psychological composure,
evening psychological exhaustion, somatic
symptoms in sleep, dream recall, sleep –wake
regulation
Sleep latency is an obvious focus for
questionnaires on insomnia. The process of
sleep onset should be more completely
investigated, both clinically and scientifically
Past 2 weeks Two four-point-scale items: Difficulty falling
asleep, taking ,5 min to fall to sleep
Relatively theory-independent outcome
measures are desirable for enabling
generalizable comparisons of results across
various kinds of efficacy and theory-based
studies
Past week Thirteen VAS items covering nighttime and
daytime symptoms
Past month Eight four-point-scale items covering nighttime
and daytime symptoms
Past week Sixty-five four-point-scale items. Domains of
nighttime/daytime symptom distress, sleep
parameters, and quality of life. Under
evaluation. Available from the authors of this
paper.56
Indefinite Ten VAS items with some comparing experience
with a hypnotic to that of usual experience.
Asks about sleep onset, sleep quality,
awakening quality. Available in French47
Epidemiological studies provide prevalence
data, allow development of new hypotheses,
and inform public health polices about insomnia
and its treatments
(continued on next page)
186 D.E. Moul et al.

Table 2 (continued)
Conceptual Questionnaire Time-frame Commentsb
frameworka

Angst’s questions58
Chevalier’s questions59
Hatoum’s questions60
Sleep problems
questionnaire18
Léger’s Q1 Questionnaire61
SLEEP-EVAL30
Composite international
diagnostic interview (CIDI)29
Indefinite Ten VAS scale items. Covers nighttime sleep
difficulties, panic, nightmare, being unrested,
daytime sleepiness, sleep worry.
Past month Three three-point-scale items for nighttime
(sleep latency .20 min, difficulty returning to
sleep, ,6 ho sleep) and one three-way
(tired/irritable/neither) daytime item
Indefinite Five Yes/No items. Insomnia graded into Level I
and Level II severity
Past month Four five-point-scale frequency items: trouble
falling asleep, waking up at night, trouble
staying asleep, awakening tired
Indefinite Four three-point-scale items written in French.
Estimates diagnoses of DSM-IV primary
insomnia, grading insomnia into mild and severe
Various Computer assisted personal interview (CAPI)
system in which an interviewer asks verbatim
questions given by the computer. It makes
diagnostic classifications for DSM, ICSD, and ICD
systems under conditions of inferential
uncertainty. Translated for use in several
languages
Various Historical descendent of the Diagnostic
Interview Schedule. Able to make DSM and ICSD
diagnostic estimates with a structured
interview

Behavior therapies
Sleep A generally useful clinical focus, yet definitions
hygiene of sleep hygiene vary, and appropriate sleep
behaviors may vary by age group
Sleep hygiene awareness and Past week Actually three scales: Sleep Hygiene Knowledge
practice scale41 (13 seven-point-scale items), Caffeine
Knowledge (18 Yes/No items), and Sleep
Hygiene Practice (19 items counting
days/nights of particular activities)
Sleep behavior self-rating Indefinite Twenty five-point-scale items. Contrasts
scale62 bedtime and daytime items
Sleep hygiene questionnaire63 Indefinite Ten Yes/No items asking about particular
practices
Sleep behaviors scale: 60 þ 35 Indefinite Thirty five-point-scale items. Factors of active
behaviors (11 items), relaxation (8 items), and
cognitive arousal (5 items). Normed on an aging
sample
Relaxation Scales for rating physical tension have been
training rather overlooked, and are needed to help
distinguish somatic from cognitive stimuli that
may interfere with sleep in insomnia patients
Tension thermometer35 Now A single VAS from ‘not at all tense’ to ‘very
tense’
Stimulus A useful motivating concept for many
control behavioral interventions. For clinical and
theoretical reasons, more specificity in stimulus
identification and specific stimulus-response
patterns is needed
Practice record-stimulus Today Six mixed-format daily items for clinical logging
control41 across one week
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Self-report measures of insomnia in adults: rationales, choices, and needs
Table 2 (continued)
Conceptual Questionnaire
frameworka
Sleep
restriction
The Pittsburgh sleep diary64
The Karolinska sleep diary65
DGSM-
Abend/MorganProtokolle
für Schlaffuntersuchungen66
Johns’ Instrument67
Sleep questionnaire68
Morin’s sleep diary22
Lacks’ daily sleep diary41
Visuelle Analogskala zur
Erfassung von
Schlafqualität (VIS-A)69
Cognitive-
behavioral
Insomnia severity index13
Dysfunctional beliefs and
attitudes about sleep scale22
Dysfunctional beliefs and
attitudes about sleep scale-10
Fragebogen zu
schlafbezogenen
Kognitionen70
187
Time-frame Commentsb
Sleep log data addresses the therapeutic
mechanism of sleep restriction because they
provide subjective sleep parameters
Today Twenty-three complex mixed-format items.
Records daily food and drug intakes, sleep
parameters, nocturnal events, daytime naps,
exercise, and ratings of sleep quality, mood and
alertness
Today Thirteen mixed-format items plus a derived
sleep efficiency items. Records sleep
parameters and sleep quality items
Today Twenty-seven complex mixed-format items
written in German with separate evening and
morning reports. Reports daily food and drug
intakes, sleep parameters, nocturnal events,
daytime naps, sleep hygiene, and bedtime
arousing-stimulus items
1 Week Eleven mixed-format items. Reports sleep
parameters by weekday/weekend, sleep
quality, nightmare frequency
Today Nine mixed-format items with item definitions.
Reports sleep parameters, napping, quality
rating, and medication use. Designed for use in
aging samples
Today Ten mixed-format items. Reports sleep
parameters, napping sleep aid/alcohol use,
morning refreshment and sleep restedness
Today Ten mixed-format items. Reports some sleep
parameters, with items on sleep difficulty,
mental/physical activation, and daytime
functioning
Today Twenty-eight mixed-format items written in
German. Has evening (daily feeling summaries,
napping report) and morning (awakening
quality, sleep parameters) sub-forms
The cognitive perspective postulates that
adverse mental events occur between the
intention to sleep and actual sleeping. Thoughts
interfere with sleep in many patients. In some,
the interfering events are images. Still others
identify no mental events interfering with
sleep. Thus, many questionnaires are needed
for the cognitive perspective on insomnia
Past week Seven five-point-scale items. Domains of
insomnia severity, sleep worry, functional
impairment, social concern, and sleep
satisfaction
Indefinite Thirty VAS items. Themes of consequences of
insomnia, control and predictability of sleep,
sleep requirement expectations, causal
attributions of insomnia, and sleep-promoting
practices
Indefinite Ten items from the DBAS. Factors of immediate
consequences, long-term consequences, and
need for control
Indefinite Thirty four-point-(never to always)-scale items
written in German. Factors of sleep anxiety,
catastrophizing, self-composure, positive self-
instructions, and beliefs about medication use
(continued on next page)
188
Table 2 (continued)
Conceptual Questionnaire
frameworka
Penn State worry
questionnaire: past week71
Hewitt’s multidimensional
perfectionism scale72
Anxious self-statements
questionnaire73
The Self-Statement Test:
60 þ 74
Post-sleep evaluation
questionnaire
Floyd-Medler sleep beliefs
scale75
Expectancy
and
acceptability
Self-efficacy scale41
Insomnia treatment
acceptability scale22
Impacts and states
Insomnia
impacts
Quality of life of insomnia19
Sleep effects index76
Insomnia impact scale (IIS)17
Sickness impact profile (SIP)77
D.E. Moul et al.
Time-frame Commentsb
Past week Fifteen six-point-scale items. Focused on
general pathological worrying, possibly distinct
from sleep worry
Indefinite Fifteen seven-point-scale items in publication;
45 items discussed. Domains of self-oriented
perfectionism, other-oriented perfectionism,
social prescribed perfectionism. Perfectionism
is a possible impediment to sleep
Past week Thirty-two four-point-scale frequency-based
items. Factors of a) inability to maintain coping
and a negative view of the future, b) self-
doubt/questioning, and c) confusion and worry
about future plans
Indefinite Thirty-four five-point-scale frequency-based
items asking about thoughts during
wakefulness. Factors of generalized positive
thinking, generalized negative thinking, and
sleep-related thoughts
Today Twenty-eight VAS items with Yes/No lead-in
branch points. Asks about thoughts, mental
images, emotions, and bodily sensations that
occurred during prior night’s sleep onset.
Available from the authors of this paper
Indefinite Twenty-five five-point-scale items for use in
normal adults. Dimensions of next-day
consequences, health consequences, sleep
need, psychological consequences, sleep
regularity, white noise, coping strategies,
sleeping in, and napping
Treatment effectiveness may depend upon how
the patient views the insomnia problem or the
offered treatment
Indefinite Nine five-point-scale items. Describes self-
efficacy about sleeping
Indefinite Sixteen VAS items. Domains for behavioral and
pharmacological treatments
Documenting the behavioral, emotional, and
health consequences of insomnia is important
for justifying the public health need for
research on insomnia
Indefinite Fifty mixed-format items mainly focused on
domains of daily functioning. Translated into a
number of languages
Past week Twenty-five five-point-scale items. Factors of
non-clinical dysphoria, sleepiness/cognitive
inefficiency, motor impairment, and social
discomfort
Past 2 Weeks Forty five-point-scale Agree/Disagree items
focusing on insomnia-related distress symptoms
Indefinite One hundred and thirty-six Yes/No items. Main
dimensions of physical, psychosocial, and
independent categories. Categories of
ambulation, mobility, body care and
movement, social interaction, alertness,
behavior, emotional behavior, communication,
sleep and rest, eating, work, home
management, recreation, and pastimes
(continued on next page)
Self-report measures of insomnia in adults: rationales, choices, and needs
Table 2 (continued)
Conceptual Questionnaire
frameworka
SF-3620
Marchini monitoring
inventory78
Léger’s Q2 questionnaire79
Arousal
Hyperarousal scale80
Arousability predisposition
scale81
Pre-sleep arousal scale82
Activation-deactivation
adjective checklist short form
The multidimensional anger
inventory84
Fatigue
Multidimensional fatigue
inventory (MFI-20)85
Global vigor and affect
instrument86
FACES87
Sleepiness
Epworth sleepiness scale88
Stanford sleepiness scale89
189
Time-frame Commentsb
Past month Thirty-six five-point-scale items. Indices for
physical function, role physical, role emotional,
mental health, vitality, social, general health.
Popular, but not designed specifically for
insomnia
Now Twenty-one five-point-scale items. Reports on
daily activity rates
Indefinite Fifty-four Yes/No items written in French.
Consequence domains include domestic
aspects, physical fatigue, motivation,
neurocognitive aspects, psychological fatigue,
occupational, driving/accidents, leisure, family
relations, and social relations
To move beyond the truism that arousal
prevents sleep, ‘arousal’ will need to be defined
in relation to something other than the
likelihood of sleeping. These questionnaires
assess dimensions of arousal possibly relevant
to insomnia research
Indefinite Twenty-six four-point-scale items focusing or
reactivity to events and stimuli
Indefinite Twelve five-point-scale frequency-based items
focusing on reactivity
Indefinite Fifteen five-point-scale items concerning pre-
sleep experiences. Domains of cognitive and
somatic arousal
Now Twenty four-point-scale items. Factors of
general activation, high activation, general
deactivation, deactivation-sleep from the AD
ACL long form83
Indefinite Thirty-eight five-point-scale items. Factors of
anger arousal, range of anger-eliciting
situations, hostile outlook, anger-in, and anger-
out
Fatigue is a common, non-specific symptom of
insomnia patients that needs more careful and
precise descriptions
‘Lately’ Twenty five-point-scale items. Subscales of
general fatigue, physical fatigue, reduced
activity, reduced motivation, and mental
fatigue
Today Eight VAS items. Domains of global vigor, global
affect
Sixty-five four-point-scale items. Subscales for
Faces, Anergy, Consciousness, Energized, and
Sleepiness
Some insomnia patients seem to feel sleepy, yet
may not be able to sleep or to nap. What they
report when reporting sleepiness remains
unclear
Past week Eight four-point-scale items rating the
‘tendency to doze’ in particular situations.
Available in French.47
Now One item with seven ordinal categories. There
is evidence it has separate, embedded factors
of activation and sleepiness. Available in
French.47
(continued on next page)
190 D.E. Moul et al.

Table 2 (continued)
Conceptual Questionnaire Time-frame Commentsb
frameworka

The sleep–wake activity Indefinite Fifty-nine VAS items. Factors of excessive

inventory90 daytime sleepiness, psychic distress, social
desirability, energy level, ability to relax, and
nocturnal sleep. Intended as a sleepiness scale
Daytime sleepiness scale54 Past 2 Weeks Eight four-point-scale items: Fell asleep as
passenger, drowsy when still, asleep when with
friends, asleep during conversations, drowsy
driving, sleepy after reading, and dosing when
relaxed

Anxiety and Depression and anxiety are likely both causes

depression and consequences of insomnia, but the causal
sequences are not always clear, and the
relationships may vary from person to person.
Too many scales to mention here
Somatic Somatic symptoms may impair sleep.
focus Estimating the degree of focus patients have on
somatic symptoms is important in
understanding an insomnia complaint. (Pain
metrics not included here)
Somatic symptom inventory91 Indefinite Twenty-six five-point-scale items about various
somatic sensations

Extrinsic factors
Stress and Stressful events and strains may precipitate or
strain maintain insomnia. Likewise, insomnia may
itself be a stress or strain. In either case, some
assessment of stresses and strains is warranted
Impact of event scale92 Past week Fifteen four-point-scale items. Subscales of
intrusive thoughts and avoidance behaviors
Life events scale93 Past 6 Ten Yes/No items about events: separations,
months deaths, illnesses, retirement, household
moves, being a victim of crime, loss of driver’s
license, money problems. Designed for aging
populations. One among many life events
checklists available
Circadian Insomnia complaints often accompany irregular
or non-standard sleep–wake activity patterns.
Summary measures of these patterns may help
to place an insomnia complaint in context
Morning–eveningness Indefinite Nineteen mixed-format items. Provides a
questionnaire94 summary score along the dimension of
morningness-eveningness. Available in French
[47: 2403]
Social rhythm metric36 Daily Fifteen time-reporting items about regular daily
activities. Designed to quantify the overall
regularity of activities
a
This framework is provided only to generate convenience categories in the presentation of a heterogeneous collection of
questionnaires.
b
We attempted to format comments with as much consistency as possible. However, because of the heterogeneity of the
instruments, the formatting could not be entirely consistent without misrepresenting the unique qualities of the questionnaires.
c
We use the term ‘subscales’ to refer to authors’ intentions to provide sub-metrics, ‘domain’ to refer to generalized themes in a
questionnaire, ‘factor’ to refer to results from factor analyses, and ‘report’ to refer to sleep parameters or more concretized
information.

design instruments that are properly tuned to their Theory-based instrumentation lives on the fron-
theories, and select instruments with appropriate tier of self-report questionnaires because theories
validities suitable for answering their own theory- place greater demands on discriminating between
based research questions. potential causal explanations. Improved testing of
Self-report measures of insomnia in adults: rationales, choices, and needs
theories must not only measure end-point dimen-
sional outcomes, but also attempt to confirm or
disconfirm theoretical accounts of the series of
events or phenomena occurring with poor sleeping
and during various therapeutic transformations.
Many current self-report instruments do not address
this requirement for theory testing. On the other
hand, the psychologies of self-monitoring23 and of
self-interpretation24 raise methodological difficul-
ties that may have special characteristics in
insomnia. Since the interface between distress
and perceived insomnia remains a quandary,25
future theory-based questionnaire development
can be expected to take advantage of knowledge
advancements regarding perceived insomnia dis-
tress and its influences over other questionnaire
responses.
Results from studies that rigorously test process
theories in behavioral interventions will help
clinicians select and monitor interventions for
various subtypes of insomnia patients. Having
good process theories that clearly explain the
mechanisms of action of various interventions will
enhance the intelligibility of interventions,
increase their clinical specificity, and facilitate
their export to everyday clinical settings.
Scenario #3: epidemiological, case
control, and genetic studies:
observational studies
An ‘observational study’ generally refers to a study in
which the investigator collects information largely
without manipulating therapeutic or other
exposures: The researcher just ‘observes.’ Observa-
tional studies fall into two general types. The first
type of study focuses on population descriptions,
ideally using samples drawn randomly from prob-
ability-weighted population strata. The second kind
of study focuses on analyzing available data to find
risk factors for a particular disease or disorder. The
second, analytic type of study can also use random
samples, but often forms comparator groups based on
outcomes observed in convenience samples. Studies
that sample on the basis of outcome are called case–
control studies. Case–control studies are often used
by clinical researchers when they explore for differ-
ences between insomnia patients and controls,
because the diagnosis serves as the outcome and
the researcher is looking for potential risk factors.
Genetic studies fall within the general class of
observational studies as well. There is a wide variety
of observational study designs,26 so our generalizing
about them here should be taken as heuristic.
191
What is the general kind of question that is
asked in studies of epidemiological or case – control
studies of insomnia in populations? The main aim of
many epidemiological studies is to characterize the
pattern of disease or disorder in the target
population. Classifying people accurately is often
more important than scaling a latent construct. For
good epidemiological studies, high diagnostic speci-
ficity is usually a high priority. Yet in a number of
preliminary studies, insomnia prevalence was esti-
mated from answers to inadequate questions like
‘Do you have insomnia?’ without defining insomnia
as a condition. In those preliminary studies,
respondents that endorsed having insomnia were
perforce required to use their own definitions,
which is exactly contrary to the goal of accurate
classification of cases. In good epidemiological
work, much attention is focused on the definition
of diseases or disordered functioning, the nature of
the population studied, potential sampling biases,
and potential measurement problems.
What are the measurement priorities in observa-
tional studies on insomnia? If the study is focused on
measuring general disability in the population, then a
high priority attribute for instrument selection is high
sensitivity. This means that the instrument identifies
as many persons as possible who have the disease or
condition. General disability questions are asked by
investigators planning medical services or formulat-
ing government policies, tasks where it is more
important to know what medical service demands a
population may make than it is to know exactly what
their medical conditions are.
Yet for most epidemiological studies, and
especially for case – control studies, the diagnostic
specificity of an instrument is an especially high
priority because these studies usually focus on one
or more specific diseases or disorders. Case defi-
nitions of insomnia vary considerably across
studies, yet case definitions are the core of these
study designs. For example, an epidemiologically
useful insomnia instrument should differentiate
depression-related insomnias from psychophysiolo-
gic or primary insomnias. In these circumstances,
sensitivity has some importance, since there is a
severity spectrum of insomnia in the population,
but it is not the main priority if unambiguous risk-
factor analysis is attempted. To guard against
confounding, the measurement of co-morbidities
and independent risk factors are additional high
priorities in analytic epidemiological studies,
especially in longitudinal and case – control studies.
Less important attributes are continuous measure-
ment scaling, transparency of scoring, multidimen-
sional scaling, and detailed reviews of symptoms that
are not directly linked to the syndromal definition(s).
192
Low priority attributes for epidemiological studies
are psychological construct validities, theory-depen-
dence, or treatment responsivity.
What practical constraints should be weighed in
selecting an instrument for a epidemiological study?
In epidemiological studies, a study’s quality hinges on
getting a large sample size in order to obtain
prevalence or incidence estimates with narrow
confidence intervals and on minimizing potential
non-response bias. It is better if the instrument or
interview can be easily completed by respondents
from a wide range of backgrounds and with a
minimum of ambiguity and bias. Question wording,
hierarchy, and ordering are critical for a study’s
knowledge value, so much so that pretesting
the questionnaire may be mandatory. Using
branching question structures that drop non-pro-
ductive lines of questioning may improve the instru-
ment’s performance by reducing its usual length, but
runs the risk of respondents using ‘no’ answers to
shorten the data collection process. In some circum-
stances, use of a computer-assisted phone interview
(CAPI) may be best, but this may be a problem if the
sample population does not have a phone, or does not
answer phone requests. Pretesting the interview
should also address recall biases. In field studies,
training and paying interviewers, photocopying
forms, and managing data quality impose substantial
costs. In circumstances where the insomnia
researcher is inserting substudy questions into a
larger epidemiological study, the overall adminis-
trative fit between the instrument and the other
instruments used in the study should be assessed.
Will one or more instruments suffice for obser-
vational studies, or is there a need for better
instruments? Early innovators in the epidemiology
of insomnia were Balter et al.,27 who constructed
an interview from questions on the Hopkins Symp-
tom Checklist-90. This approach probably favored
sensitivity, but did not instrument psychiatric
syndromes very well, which are major confounds
of primary insomnia diagnoses. Some investi-
gators18 have devised short question sequences
designed to gain estimates of insomnia prevalence,
without regard to diagnosis. Short question
sequences may overlook relevant nighttime or
daytime symptoms, so present some risk of missed
findings. Such approaches may be more useful for
services planning or policy formulation.
By contrast, Ford and Kamerow,28 utilizing data
from the Diagnostic Interview Schedule (DIS), also
provided some prevalence estimates from the
Epidemiologic Catchment Area Study but in
reference to formally modeled psychiatric diag-
noses. The DIS is a structured interview given to
respondents by trained interviewers, written to
D.E. Moul et al.
estimate diagnoses from the DSM of the American
Psychiatric Association.3 The DIS and the Compo-
site International Diagnostic Interview (CIDI)29 (its
historical descendant) are a reasonably good
instruments to use where direct interviewing is
possible. However, the DIS was not designed with
insomnia as its central focus, so nocturnal
symptoms are not explored in depth in the DIS
or CIDI. In recent years, Ohayon30 has developed a
computer-assisted interview (SLEEP-EVAL) that
can be used to estimate prevalence not only of
primary insomnia, but also of other confounding
conditions. It can provide research diagnostic
classifications based both on the DSM system,
and with the ICSD.2 The SLEEP-EVAL interview also
offers the advantage of distinguishing between
sleep dissatisfaction and a clear insomnia com-
plaint. Its disadvantage is that it, like the DIS,
does not query nocturnal symptoms in depth. For
more clinically based studies, the Structured
Clinical Interview for DSM-IV Axis I Disorders31 is
a well-regarded interview that reviews psychiatric
diagnoses systematically (but not sleep disorders).
More recently, Schramm et al.32 have developed
the Structured Interview for DSM-III-R sleep
disorders, although symptoms are not explored
in detail. These latter two interviews are clinically
based.
Because sleeping pill use is often a topic of
some public concern, epidemiological studies of
insomnia often are concerned with the estimation
of sleeping pill use. Pharmacoepidemiological
components to such studies add significantly to a
study’s design complexity. Since benzodiazepine
medications can be used as both hypnotics and
anxiolytics, disentangling whether prescriptions
were given appropriately involves not only deter-
mining what medication was actually prescribed
and how it was consumed, but also whether the
medication was actually prescribed uniquely as a
hypnotic for ‘pure’ insomnia. The latter methodo-
logical problem, called confounding by indication,
is a very common problem in pharmacoepidemio-
logical studies.33 Simply measuring pill usage is
largely uninformative, so studies investigating
the appropriateness of prescribing and use
require careful methodological fits between
the epidemiologies of the insomnias and mental
health with the epidemiologies of psychotropic
use. The best methods for determining pill use
involve the use of color photographic displays of
pills or actual inspections of home medicine cabi-
nets. Actually taking blood levels or doing daily pill
counts is impossible in epidemiological studies. In
some cases, likelihood-of-indication markers are
postulated from dose/frequency relationships
Self-report measures of insomnia in adults: rationales, choices, and needs
(e.g. trazodone 50 mg qhs), which may be a useful
strategy, but might not address use for insomnia
versus for nightmares. Since both determining the
medications taken and the indications for use
involve possible faults of memory in the respon-
dents, special methodological difficulties await
researchers who desire to understand whether
hypnotics are prescribed appropriately for insom-
nia, and whether such prescribing is safe and
effective.
Epidemiological studies largely depend upon
definitions of disease or disorder. With this in
mind, the SLEEP-EVAL, or perhaps the CIDI, may
be regarded as acceptable instruments for epide-
miological studies if interviewers can be used.
This is the usual context in which epidemiological
studies are conducted, owing to the need to
manage the sampling protocols. These interviews
offer some measures of competing causes of
insomnia other than primary insomnia. Advance-
ments in knowledge about insomnia are now likely
to require improvements in such instruments
tailored to answer specific questions about risk
factors for or consequences of insomnia. For
services research studies, Jenkins’ questionnaire
may provide good information with a minimum of
subject burden. Given the public concern about
whether sleeping pill use is appropriate or not,
pharmacoepidemiological instrumentation will
continue to be an enduring methodological chal-
lenge. Currently, there are no standardized
instruments available for pharmacoepidemiologi-
cal studies of hypnotics.
Scenario #4: geriatric insomnia
What is the general kind of question that is asked
in studies of geriatric insomnia? The heterogeneity
in health statuses in aging populations makes it
unlikely that there is one general kind of question.
Even by itself, normal aging reduces slow-wave
sleep, increases the number of awakenings, light-
ens sleep, and possibly reduces the homoeostatic
drive for sleep. Extrinsically, retirement from work
generally results in fewer daily scheduled events,
which may also influence the timing of sleep and
napping. Many aged persons also develop health
conditions too numerous to list here. Furthermore,
not all retirements are financially or socially
secure. The elderly renegotiate their philosophies
of daily activities and sleeping (e.g. of napping)
across a range of opportunities and constraints.
Physical disabilities, disabilities in spouses, wor-
ries, cognitive brittleness, reduced coping skills,
193
and monotonous daily routines all may facilitate
difficulties with sleeping. Medication use often
sustains one’s independence, and use of hypnotics
may be more acceptable than earlier in life. Stroke or
dementia may further injure a person’s ability to
regulate one’s sleep–wake schedule, and lead to
institutionalization. These and other considerations
imply that the study designs used in aging studies are
likely to require a careful subgroup focus and/or great
care in selecting instruments to measure confounding
variables.
What are the measurement priorities in aging
studies on insomnia? Specificity in measuring health
conditions is an obvious high priority. An additional
high priority is the specification of cognitive level,
both as a health correlate, but also as cognitive
impairment may affect self-reporting. For a symp-
tom such as insomnia, the measurement issues are
likely to resemble those observed in geriatric
depression, as follows. In the Epidemiologic Catch-
ment Area Study, data from the DIS supported the
conclusion that depression was not a highly preva-
lent problem in the aged; however, a separate
study in a large substudy using the Present State
Examination suggested otherwise.34 Evidently, the
way DIS wording and criteria were organized did not
reflect how the elderly themselves might report
poor mood functioning. Due to cohort biases or
cognitive changes, the elderly may report symp-
toms of demoralization, depression, or insomnia in
different ways from younger populations. Thus, it is
important that the selected instrument(s) used
reflect how the elderly subpopulation thinks about
its sleep and other life difficulties.
What practical constraints should be weighed in
selecting an instrument for study among the
aging? One clear difficulty is whether to approach
the measurement of insomnia more in a categori-
cal sense, or in a dimensional sense. The potential
value of conceptualizing insomnia diagnostically is
that criteria can be stipulated across subpopu-
lations. This diagnostic approach is more appro-
priate for case – control studies, where stark
contrasts are desired. Yet the dimensional
approach may guide instrumenting chronic insom-
nia more meaningfully. It will be even more
difficult to place 80-year-olds into diagnostic
subtypes of insomnia than it is to classify 20-
year-old insomniacs into such archetypes. Investi-
gators cannot ignore the implications of choosing
between these approaches. In addition, minimizing
respondent burden by selecting shorter instru-
ments with simply worded items may provide
better information across the aged study sample.
When investigators need face-to-face interviews,
the interviewers should have the skills for working
194
with the selected aging subpopulation(s). Using
skilled interviewers is a trade-off against rote
standardization, since the interviewers may introduce
biases by virtue of their expertise or prior experience.
Will one or more instruments suffice for
insomnia studies in the aging, or is there a need
for better instruments? The shallower and more
fragmented sleep of normal aging poses interest-
ing challenges for investigators in differentiating
normal sleep from sleep that is dissatisfying to the
person but not a medical complaint, and from
sleep that generates a complaint but no obvious
PSG abnormality. The SLEEP-EVAL examination by
Ohayon appears to approach this question to some
extent in epidemiological studies, but it is not
clear that the SLEEP-EVAL exam is fully ready for
aging population studies. At more clinical levels,
Fichten and colleagues have approached the
question of instrumenting sleep distress in the
aged with the Sleep Behaviors 60 þ Question-
naire35 in concert with an ensemble of other
measures. The work of Morin and colleagues has
likewise established the suitability of the SII in
studies of aging insomnia patients. Monk’s Social
Rhythm Metric36 must be regarded as especially
relevant in examining the circadian stability of the
daily regimens of aging persons. While not ‘insomnia’
in the usual sense of the term, the extremely light and
fragmented sleep of demented elderly patient also
requires evaluation from the standpoint of the elder’s
caregiver. Clearly, some investigators have begun
useful lines of inquiry regarding insomnia in the
elderly, but sleep research on the aging will continue
to need specially adapted questionnaires (1) to
understand elderly subjects’ beliefs and experiences
of sleeping and activity regulation, and (2) to assist
with identifying and assessing patterns of poor
sleeping as they may affect health outcome and
social independence.
Questionnaire development needs
for the insomnia field
Insomnia research at this time probably is in a
similar situation to psychiatric research in the 19th
century in that even the definitions of the terms
employed remains open to debate. Resolution of
such debates will depend partly on review of data
provided by self-report questionnaires, as designed
for different populations and from differing theoreti-
cal perspectives. Thus, progress in insomnia research
will depend in part upon advancements in question-
naire design. From this review, several needs for
questionnaire development can be identified:
D.E. Moul et al.
1. Past-week insomnia rating scale integrating
daytime and nighttime distress, subjective
sleep parameters, and quality of life domains
for use in outcome-based studies.
2. An instrument for the kind of subjective sleepiness
that insomnia sufferers endorse (i.e. feeling
sleepy, but being unable to sleep or nap). Such
an instrument may require careful empirical
studies of ‘sleepiness’ semantics among chronic
insomnia patients.
3. Improved instruments for tracking stimulus con-
trol and cognitive behavior therapy interventions
in the in-bed time domain.
4. Instruments to clarify kinds of arousal between
general activation, deactivation, generalized
anxiety, sleep anxiety, general worry, sleep
worry, non-pathological worry, somatic acti-
vation, paradoxical fatigued alertness, and
‘pure’ alertness at bedtime.
5. Improved screening instruments for use in pri-
mary care, designed to assist in triaging insomnia
complaints between depressive, anxiety, medi-
cal, and primary insomnia disorders.
6. Instrumentation for understanding how insomnia
patients decide between treatments that may be
offered, especially in the framework of relative
utility and cost-benefit thinking.
7. Improved techniques for experience sampling
insomnia patients during the daytime.
8. Improved longitudinal instruments to track the
course of insomnia, with ability to detect period-
icities of episodes. Such instruments could be
especially useful if they enabled the distinction
between qualitative classes of sleep: good sleep,
adequate sleep, dissatisfying but tolerable sleep,
sleep that causes a medical complaint, and
insomnia that causes substantial daytime distress
or disability.
9. Since so many studies rely on case – control
methodology, there is a great need for the
development of diagnostic questionnaires and
interview schedules that can select kinds of
insomnia with high grades of definitional speci-
ficity. Without this, finding risk factors for
different kinds of insomnia will be much more
difficult.
10. Better instruments to place insomnia in the
context of multiple medical comorbidities.
11. Improved methods to query hypnotic medication
use in populations, in both primary and secondary
data sources, with specialized techniques to
account for confounding by indication.
12. Since insomnia is a risk factor for institutional
placement of demented persons living in
the community, caregiver-based questionnaires
designed to identify poor sleeping in demented
Self-report measures of insomnia in adults: rationales, choices, and needs
persons may assist in targeting caregivers for cost-
effective interventions.
Conclusion
Designing studies about insomnia in adult popu-
lations begins with the problem of the definition
of insomnia itself. Even after an investigator
decides what definition to select for a study, he
or she must still consider carefully what self-
report measures to use. The process of selecting
an ensemble of questionnaires wisely begins with
consideration of factors that include the popu-
lation sampled, the kind of study anticipated, and
the theory of insomnia that is modeled. Where
reasonable, there are significant scientific benefits
from using questionnaires that others have devel-
oped and/or characterized. However, whether an
investigator is using a well established question-
naire or inventing a new one, it remains his or her
responsibility to consider the reliability and
validities of the questionnaires used if the study
is to contribute to the advancement of knowledge
about insomnia.
Practice points
† While insomnia is a common problem with
diverse causes, its consequences span
nighttime distress, sleep parameters (e.g.
sleep latency, hours of sleep), daytime
distress, functional impairments, and
decreased quality of life.
† A variety of insomnia-related instruments
are available for use in clinical settings.
Selecting the ‘best’ questionnaire for a
particular clinical practice context involves
considering carefully how the questionnaire
will exactly help screen, diagnose, or
monitor the specific clinical population
served.
† Great caution is needed when interpreting
epidemiological studies of sleeping pill use,
whether they report in favor or against such
use. Such studies usually cannot properly
address the reasons and contexts in which
prescribing was actually undertaken.
195
Research agenda
General goals include:
† Validation of insomnia as a unique syndrome
through identification of potential
biomarkers that may be correlated with
insomnia self-report data.
† Integrated and consensus-based multi-
domain descriptions of insomnia, collected
prospectively and with various time-frames
of self-reports.
† Development of improved instruments for
use in clinical trials, theory tests,
observational studies, and aging studies.
Acknowledgements
The authors thank David Kupfer, M.D., Ronald Dahl,
M.D. and Anne Germain, Ph.D. for helpful sugges-
tions. This work was supported by grants AG15138,
AG00972, MH30915, MH16804 and MH01554. The
authors also thank the peer reviewers of this article
for helpful suggestions.
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