Athens Insomnia Scale (AIS)

Introduction to the Athens Insomnia Scale (AIS)

The Athens Insomnia Scale (AIS) is a self-assessment tool developed to quantify the severity of insomnia based on the diagnostic criteria outlined in the International Classification of Diseases (ICD-10). The ICD-10 is a standardized system developed by the World Health Organization (WHO) for classifying diseases, health conditions, and related health problems. It assigns unique alphanumeric codes to various medical diagnoses, symptoms, and procedures, facilitating consistent recording and reporting of health information worldwide.

This system is widely used for clinical purposes, health management, and epidemiological research.Introduced in 2000 by researchers from Athens, Greece, the AIS evaluates various aspects of sleep difficulty and has been validated across diverse populations, including patients with insomnia and psychiatric disorders.

As a Sydney psychologist, I use the AIS to help clients identify sleep issues – complete it below to assess your own sleep health.

Components of the AIS

Sleep induction – the ease or latency of falling asleep (how long it takes to initiate sleep).
Awakenings during the night – disturbances due to waking up in the middle of the night (frequency and severity of nocturnal awakenings).
Final awakening earlier than desired – whether the person wakes up too early in the morning and cannot resume sleeping.
Total sleep duration – the total amount of sleep obtained (perceived sufficiency of sleep length).
Overall quality of sleep – the subjective quality of sleep (how restful or satisfactory the sleep was).
Sense of well-being during the day – the individual’s general feeling of well-being during the day (mood and comfort, as influenced by sleep).
Functioning capacity during the day – daytime functioning on physical and mental tasks (ability to perform daily activities, concentration, energy levels).
Sleepiness during the day – the level of daytime sleepiness (tendency to doze off or feel sleepy during the day)

Each item is rated on a scale from 0 to 3, where:

0: No problem
1: Slightly delayed/minor problem
2: Markedly delayed/considerable problem
3: Very delayed/serious problem or did not sleep at all

The total score ranges from 0 to 24, with higher scores indicating more severe insomnia symptoms.

Complete the Athens Insomnia Scale (AIS)

Interpreting AIS Scores

In general, higher AIS scores correspond to greater severity of insomnia. In clinical use, a cutoff score of 6 on the AIS is often used to identify the presence of clinically significant insomnia. Research on the diagnostic properties of the AIS found that a total score ≥6 optimally differentiates individuals with insomnia from those without insomnia.

At this threshold, the AIS demonstrates approximately 93% sensitivity and 85% specificity.

Sensitivity refers to the test’s ability to correctly identify those who have the condition. A sensitivity of 93% means that out of 100 individuals with insomnia, the AIS will correctly identify 93 of them, while 7 may be missed (false negatives).

Specificity indicates the test’s ability to correctly identify those without the condition. A specificity of 85% means that out of 100 individuals without insomnia, the AIS will correctly identify 85 as not having the condition, while 15 may be incorrectly identified as having insomnia (false positives).

In practical terms, if someone scores 6 or above on the AIS, there’s a high likelihood they are experiencing clinically significant insomnia. Conversely, a score below 6 suggests that any sleep issues present are likely not at a clinically significant level. It’s important to note that while the AIS is a useful screening tool, a comprehensive evaluation by a healthcare professional is essential for an accurate diagnosis.

In other words, AIS scores 0–5 generally indicate no or minimal insomnia symptoms, while scores ≥6 signal the probable presence of an insomnia disorder. The higher the score above 6, the more severe the insomnia is considered: for instance, a score in the teens or higher implies substantial sleep impairment affecting both night-time sleep and daytime well-being. Clinicians may use the degree of elevation in the AIS score to gauge whether insomnia is mild, moderate, or severe, even though the AIS itself is often used primarily with the single cutoff to screen for insomnia. A score of 0 would indicate normal sleep with no complaints, and intermediate scores (e.g. 6–12 vs. 13–24) can give a sense of moderate vs. severe insomnia, respectively, with all eight domains being increasingly affected as the score rises.

Validity and Reliability of the AIS

Let’s break down the concepts of validity and reliability in the context of the Athens Insomnia Scale (AIS) in a straightforward manner:

1. Internal Consistency (Reliability):

Imagine you’re taking a test with multiple questions designed to measure your math skills. If all the questions are truly assessing your math ability, your answers should be consistent across them. Similarly, the AIS has eight questions about different aspects of sleep. If these questions are all effectively measuring insomnia, the responses should be consistent. Researchers use a statistic called Cronbach’s alpha to measure this consistency. For the AIS, Cronbach’s alpha values range from 0.87 to 0.89, indicating that the questions are reliably assessing the same concept—insomnia.

2. Test-Retest Reliability:

This refers to the stability of the test over time. If you take the AIS today and then again a week later, and your sleep patterns haven’t changed, your scores should be similar. The AIS shows a test-retest reliability correlation of approximately 0.88 to 0.89 over a one-week interval. This means the scale provides consistent results over time when your sleep condition remains the same.

3. Convergent Validity:

This assesses whether the AIS aligns with other established measures of sleep problems. For instance, if you take both the AIS and another reputable sleep questionnaire, your scores should be similar if both are accurately measuring sleep issues. The AIS has shown high correlations (between 0.85 and 0.90) with other established sleep measures, indicating that it effectively assesses insomnia in line with other recognized tools.

In summary, the AIS is a reliable and valid tool for assessing insomnia. As a Sydney psychologist, I rely on its accuracy to support clients in understanding their sleep – learn how it fits into insomnia treatment.

AIS scores correlate positively with scores on the Insomnia Severity Index (ISI) and with poor sleep quality on the Pittsburgh Sleep Quality Index (PSQI), as well as with related constructs like anxiety and depression that often co-occur with insomnia

Clinical Applications of the Athens Insomnia Scale

The AIS is utilized in various clinical settings to:

Screen for Insomnia: Quickly identify individuals experiencing significant sleep disturbances.In clinical practice, the AIS is used both as a screening tool and as an outcome measure for insomnia. As a screening tool, the AIS helps clinicians quickly identify patients who likely have insomnia that meets clinical significance – using the score ≥6 criterion – in settings such as primary care, mental health clinics, or sleep centres.

Because it is brief and easy to administer, a patient can fill out the AIS in a few minutes, allowing a doctor to determine if further comprehensive insomnia evaluation is warranted. The AIS covers both nighttime and daytime symptoms, giving the clinician a holistic sense of the patient’s sleep disturbance and its impact on daily life, which is crucial for an insomnia diagnosis.

Assess Severity: Quantify the extent of insomnia symptoms to inform treatment planning. Beyond initial screening, the AIS is valuable for assessing insomnia severity at baseline and for monitoring treatment outcomes over time. Clinicians will often administer the AIS at the start of treatment to quantify how severe a patient’s insomnia is, and then repeat the scale after an intervention (such as cognitive-behavioral therapy for insomnia or the prescription of hypnotic medication) to objectively gauge improvement.

Monitor Treatment Outcomes: Evaluate the effectiveness of interventions over time by tracking changes in AIS scores. Because the AIS is sensitive to changes in sleep symptoms, a decline in the AIS total score over weeks of therapy would indicate that the patient’s insomnia is improving (e.g., if a patient’s score drops from 12 to 4, it suggests a significant resolution of insomnia symptoms). In this way, the AIS provides a standardized measure to track progress. In research trials of insomnia treatments, the AIS is often used as an outcome measure to quantify the effectiveness of an intervention on insomnia severity.

Its brevity and ease of administration make it a practical tool for both clinical practice and research.

Comparison with Other Insomnia and Sleep Assessment Tools

There are several questionnaires used to assess sleep problems. Here’s a straightforward comparison between the Athens Insomnia Scale (AIS) and the Insomnia Severity Index (ISI):

Insomnia Severity Index (ISI):

Structure: Consists of 7 questions, each rated from 0 to 4, covering issues like trouble falling asleep, staying asleep, waking up too early, satisfaction with sleep, how sleep problems affect daily life, whether others notice the sleep issues, and how worried the person is about their sleep.

Scoring: Total scores range from 0 to 28. Higher scores mean more severe insomnia.

Severity Levels:

0–7: No significant insomnia

8–14: Mild insomnia

15–21: Moderate insomnia

22–28: Severe insomnia

Athens Insomnia Scale (AIS):

Structure: Includes 8 questions, each scored from 0 to 3, focusing on aspects like sleep quality, duration, and how sleep affects daytime activities.

Scoring: Total scores range from 0 to 24. A score of 6 or higher suggests significant insomnia.

Severity Levels: While the AIS doesn’t officially categorize severity beyond the cutoff of 6, higher scores indicate more severe insomnia.

Key Differences:

Content Focus: The ISI includes questions about the individual’s worry about sleep and whether others notice their sleep problems. The AIS emphasizes how sleep issues impact daytime functioning.

Severity Categories: The ISI provides clear severity levels, which can help in treatment planning. The AIS uses a single cutoff score to identify significant insomnia.

Both the ISI and AIS are reliable and quick to complete. The choice between them depends on whether a clinician prefers a detailed severity assessment (ISI) or a focus on specific symptoms and their daytime effects (AIS).

The Pittsburgh Sleep Quality Index (PSQI):

is a self-report questionnaire designed to assess overall sleep quality and disturbances over a one-month period. It consists of 19 questions that cover seven key areas:

Subjective Sleep Quality: Your personal assessment of your sleep quality.
Sleep Latency: The time it takes you to fall asleep.
Sleep Duration: The total amount of sleep you get each night.
Habitual Sleep Efficiency: The percentage of time spent asleep while in bed.
Sleep Disturbances: Any disruptions to your sleep, such as waking up during the night.
Use of Sleeping Medication: How often you use medication to help you sleep.
Daytime Dysfunction: Difficulties staying awake or maintaining enthusiasm during the day.

Each area is scored from 0 to 3, with higher scores indicating more severe issues. The total score ranges from 0 to 21, where a higher total score reflects poorer sleep quality. A total score above 5 is generally considered indicative of poor sleep quality.

While the PSQI offers a comprehensive overview of various aspects of sleep, it is not specific to insomnia. It evaluates multiple dimensions of sleep experience to distinguish “good sleepers” from “poor sleepers.” In contrast, the Athens Insomnia Scale (AIS) focuses specifically on insomnia symptoms. Therefore, the PSQI is useful for assessing overall sleep quality, while the AIS is more targeted toward identifying and measuring insomnia.

The Sleep Condition Indicator (SCI):

is an 8-item questionnaire designed to assess insomnia based on the DSM-5 criteria. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is a handbook published by the American Psychiatric Association (APA) that provides standardized criteria for diagnosing mental health conditions. Released in 2013, it serves as a primary reference for clinicians to identify and classify mental disorders. The Sleep Condition Indicator (SCI) evaluates aspects such as the frequency and duration of sleep problems, time taken to fall asleep, sleep quality, and the impact of poor sleep on daily activities like mood, energy, relationships, concentration, and productivity. Each item is scored on a scale from 0 to 4, with higher scores indicating better sleep. The total SCI score ranges from 0 to 32, where lower scores suggest more severe insomnia. A total score of 16 or below typically indicates probable insomnia disorder.

Compared to the Athens Insomnia Scale (AIS), the SCI aligns more closely with DSM-5 criteria, focusing on the frequency and duration of sleep issues. While both questionnaires address daytime impairment, the SCI specifically asks how poor sleep affects various aspects of daily life. Additionally, the SCI’s scoring system is reversed (higher scores mean better sleep), which might be less intuitive for some users. Despite being a newer tool, the SCI has been validated in large studies and is effective for screening insomnia.

In summary, both the SCI and AIS are brief tools for assessing insomnia. The SCI is tailored to DSM-5 criteria and uses a different scoring approach, while the AIS is based on ICD-10 criteria. Both have high reliability and can help identify insomnia, with the SCI providing a clear indication for probable insomnia disorder at a score of 16 or below.

The Epworth Sleepiness Scale (ESS):

is a questionnaire that measures how likely you are to doze off or fall asleep in various everyday situations. It consists of eight scenarios, such as sitting and reading, watching TV, or being a passenger in a car. For each situation, you rate your chance of dozing off on a scale from 0 (no chance) to 3 (high chance). The scores are then added up to give a total between 0 and 24.

A total score of 0 to 10 is considered normal, indicating average daytime sleepiness. Scores between 11 and 24 suggest excessive daytime sleepiness, which could be due to various factors like sleep disorders or medication side effects. For example, a score of 11 to 12 indicates mild excessive daytime sleepiness, 13 to 15 moderate, and 16 to 24 severe.

It’s important to note that the ESS focuses on daytime sleepiness and doesn’t assess nighttime sleep quality or insomnia. Therefore, it complements other tools like the Athens Insomnia Scale (AIS), which specifically measures insomnia symptoms. Using both can provide a more comprehensive understanding of your sleep health.

Explore More Insomnia and Sleep Tools

Investigate other validated measures to assess insomnia, sleep quality, sleep hygiene, and factors like daytime sleepiness or beliefs about slepp. Track patterns with our sleep diary or visit our assessment hub for a full overview of insomnia assessment.

Insomnia Severity Index (ISI) – Gold standard self-report tool for insomnia severity over two weeks.
Pittsburgh Sleep Quality Index (PSQI) – Assesses overall sleep quality and disturbances over a month.
Athens Insomnia Scale (AIS) – Broad sleep quality, not just insomnia.
Sleep Condition Indicator (SCI) – Screens insomnia per DSM-5 with a focus on sleep satisfaction.
Epworth Sleepiness Scale (ESS) – Guages daytime sleepiness across eight everyday situations.
Sleep Hygiene Index (SHI) – Identifies sleep-disruptive habits and behaviours affecting rest.
Dysfunctional Beliefs and Attitudes about Sleep (DBAS-16) – Probes unhelpful beliefs influencing sleep difficulties.
Pre-Sleep Arousal Scale (PSAS) – Measures cognitive and physical arousal before bedtime.

Assessment Hub: Central hub for all sleep and insomnia measures.
Sleep Diary: Records daily sleep habits for personalised insights.

References

Soldatos, C. R., Dikeos, D. G., & Paparrigopoulos, T. J. (2000). Athens Insomnia Scale: Validation of an instrument based on ICD-10 criteria. Journal of Psychosomatic Research, 48(6), 555–560. https://doi.org/10.1016/S0022-3999(00)00095-7
This foundational article introduces and validates the AIS as an effective tool for assessing insomnia severity based on ICD-10 criteria.
Soldatos, C. R., Dikeos, D. G., & Paparrigopoulos, T. J. (2003). The diagnostic validity of the Athens Insomnia Scale. Journal of Psychosomatic Research, 55(3), 263–267. https://doi.org/10.1016/S0022-3999(02)00604-9med.upenn.edu
This study examines the diagnostic validity of the AIS, confirming its effectiveness in distinguishing between insomnia patients and controls.
Manzar, M. D., Albougami, A., Hassen, H. Y., Sikkandar, M. Y., Pandi-Perumal, S. R., & Bahammam, A. S. (2022). Psychometric validation of the Athens Insomnia Scale among nurses: A robust approach using both classical theory and rating scale model parameters. Nature and Science of Sleep, 14, 725–739. https://doi.org/10.2147/NSS.S325220dovepress.com
This research validates the AIS’s psychometric properties in a nursing population, employing both classical test theory and item response theory analyses.
Soldatos, C. R., Dikeos, D. G., & Paparrigopoulos, T. J. (2008). The Athens Insomnia Scale. In S. R. Pandi-Perumal, J. C. Verster, J. M. Monti, M. Lader, & S. Z. Langer (Eds.), Sleep Disorders: Diagnosis and Therapeutics (pp. 61–64). Informa Healthcare. https://www.researchgate.net/publication/281626367_The_Athens_Insomnia_Scale
This chapter provides an in-depth overview of the AIS, discussing its development, validation, and applications in clinical practice.
Campo-Arias, A., Caballero-Domínguez, C. C., & Pedrozo-Pupo, J. C. (2024). Online psychometric performance of the Athens Insomnia Scale among Colombian people. Sleep and Vigilance, 8, 245–249. https://doi.org/10.1007/s41782-024-00279-2link.springer.com
This study evaluates the psychometric performance of the AIS in an online setting among Colombian participants, confirming its reliability and validity.