The Anxiety and Preoccupation about Sleep Questionnaire (APSQ)

Abstract

The Anxiety and Preoccupation about Sleep Questionnaire (APSQ) is an empirically validated, 10-item self-report psychometric instrument engineered to quantify the severity, frequency, and cognitive intrusion of sleep-related worry in individuals presenting with insomnia and related sleep disturbances. Developed originally within cognitive behavioral frameworks of chronic insomnia by Allison G. Harvey and Nicole K. Y. Tang, and comprehensively psychometrically validated by Markus Jansson-Fröjmark and colleagues, the APSQ addresses critical gaps left by general anxiety inventories and static sleep hygiene indices. It uniquely conceptualizes insomnia as a continuous, 24-hour psychopathological process marked by both presleep nocturnal rumination and diurnal anticipatory apprehension. The instrument is comprised of two robust, correlated latent dimensions: Worries about the Consequences of Poor Sleep (Items 1–5, 7) and Worries about the Uncontrollability of Sleep (Items 6, 8–10). Respondents evaluate each item using a 10-point Likert-type continuous rating scale ranging from 1 (Not true) to 10 (Very true), referencing the preceding month. Psychometric evaluations demonstrate exceptional internal consistency across clinical and non-clinical cohorts (total scale Cronbach’s α = .93; Factor 1 α = .91; Factor 2 α = .86), with exploratory and confirmatory factor analyses supporting a two-factor structure that accounts for 70.7% of the total variance. The APSQ exhibits pronounced discriminant validity, reliably differentiating clinical insomnia patients from subclinical poor sleepers and healthy normal sleepers, and demonstrates exceptional treatment sensitivity in tracking therapeutic response following Cognitive Behavioral Therapy for Insomnia (CBT-I). This article provides a comprehensive academic analysis of the APSQ’s theoretical foundation, structural validity, psychometric properties, clinical administration, and diagnostic utility.

Keywords

Anxiety and Preoccupation about Sleep Questionnaire, APSQ, insomnia, sleep-related worry, cognitive arousal, CBT-I, psychometrics, sleep effort, metacognition, 24-hour insomnia model

Authors

The Anxiety and Preoccupation about Sleep Questionnaire was conceptualized and formulated by leading clinical psychologists in the field of sleep medicine and cognitive science:

• Allison G. Harvey, Ph.D. — Professor of Clinical Psychology and Director of The Golden Bear Sleep and Mood Research Clinic, Department of Psychology, University of California, Berkeley, Berkeley, California, USA. Formerly affiliated with the Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.
• Nicole K. Y. Tang, Ph.D. — Professor of Psychology, Department of Psychology, University of Warwick, Coventry, United Kingdom. Formerly affiliated with the Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.

The formal psychometric validation, structural factor modeling, and clinical parameter refinement of the APSQ were conducted by a consortium of behavioral medicine researchers led by:

• Markus Jansson-Fröjmark, Ph.D. — Associate Professor, Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden; and School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden.
• Lars-Gunnar Lundh, Ph.D. — Professor Emeritus of Clinical Psychology, Department of Psychology, Lund University, Lund, Sweden.
• Annika Norell-Clarke, Ph.D. — Licensed Psychologist and Associate Professor, Department of Social and Psychological Studies, Karlstad University, Karlstad, Sweden.
• Steven J. Linton, Ph.D. — Professor Emeritus of Clinical Psychology, Center for Health and Medical Psychology (CHAMP), School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden.

Purpose

The primary clinical and empirical purpose of the APSQ is to provide a precise, targeted, and psychometrically sound assessment of sleep-specific cognitive arousal and worry. Chronic insomnia is recognized not merely as a nocturnal deficit in sleep generation, but as a persistent, 24-hour disorder of psychophysiological and cognitive hyperarousal. Historically, clinicians and researchers relied on generalized anxiety inventories, such as the State-Trait Anxiety Inventory (STAI) or the Penn State Worry Questionnaire (PSWQ), or broader sleep cognition metrics like the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS). While these legacy instruments assess trait anxiety and broad, static cognitive distortions, they do not adequately isolate the recursive, intrusive worry episodes that directly trigger and sustain sleep onset latency and nighttime awakenings.

The APSQ was designed to address these methodological and theoretical limitations through several specific functional objectives:

• Isolating Insomnia-Specific Worry Content: Unlike generalized anxiety scales that measure diffuse worry (e.g., finances, relationships, generalized dread), the APSQ measures the acute cognitive distress anchored specifically to sleep duration, sleep quality, and the perceived daytime catastrophe of non-restorative sleep.
• Capturing the 24-Hour Trajectory: In accordance with contemporary neurocognitive and behavioral models, the APSQ bridges both nocturnal and diurnal phases. It assesses presleep worry occurring in bed alongside daytime anticipatory dread concerning performance deficits, somatic deterioration, and emotional lability.
• Quantifying Metacognitive Sleep Effort: A central maintaining factor in chronic insomnia is the paradoxical attempt to consciously control an involuntary biological process. The APSQ explicitly measures perceived loss of control and the distress associated with failed “sleep effort,” making it uniquely sensitive to the behavioral and metacognitive traps that perpetuate sleep disturbances.
• Tracking Clinical Treatment Response: The instrument is brief (10 items), straightforward to administer, and demonstrates minimal measurement burden. This makes it an ideal repeated-measures assessment tool for monitoring longitudinal cognitive shifts throughout courses of Cognitive Behavioral Therapy for Insomnia (CBT-I), mindfulness-based interventions, or pharmacological trials.

Psychological Construct

The construct assessed by the APSQ is sleep-related worry and cognitive preoccupation. In cognitive psychopathology, worry is operationalized as a chain of relatively uncontrollable, negatively valenced thoughts and images aimed at mental problem-solving under conditions of uncertainty. When localized to sleep, this process becomes self-perpetuating: worry induces somatic hyperarousal and autonomic activation (e.g., elevated heart rate, cortisol secretion, sympathetic dominance), which directly contradicts the neurobiological prerequisites for sleep initiation and maintenance.

Empirical structural analyses confirm that sleep-related worry within the APSQ is organized into two primary latent dimensions:

1. Worries About the Consequences of Poor Sleep (Factor 1)

This subscale comprises six items (Items 1, 2, 3, 4, 5, and 7) and taps into the catastrophic cognitive appraisals individuals generate regarding the diurnal fallout of sleep deprivation. Rather than simply evaluating physical fatigue, this dimension measures the cognitive burden of anticipating severe functional failure across primary life domains:

• Occupational and Cognitive Performance: Anticipatory anxiety regarding compromised daytime vigilance, executive functioning, sustained attention, and workplace productivity (e.g., Item 2: “I worry about how the amount of sleep I had last night is going to affect my day time performance”; Item 7: “I worry about my ability to stay awake and alert during the day”).
• Somatic Health and Physical Integrity: Hypochondriacal and health-anxiety appraisals that insufficient sleep will accelerate somatic disease, trigger immune collapse, or exacerbate chronic health conditions (e.g., Item 3: “I worry about how the amount of sleep I get is going to afflict my health”).
• Interpersonal and Social Functioning: Anxious anticipation that sleep loss will degrade social communication, patience, empathy, and interpersonal effectiveness (e.g., Item 4: “I worry about how much the amount of sleep I get will weaken my social ability”).
• Affective Regulation: Anticipatory dread that sleep loss will precipitate severe emotional dysregulation, depressive episodes, irritability, or panic (e.g., Item 5: “I worry about how much the amount of sleep I get will shake my mood”).
• Quantitative Anticipation: Obsessive calculation and presleep anxiety regarding the exact hours of sleep to be obtained (e.g., Item 1: “I worry about the amount of sleep I am going to get every night”).

2. Worries About the Uncontrollability of Sleep (Factor 2)

Comprising four items (Items 6, 8, 9, and 10), this dimension reflects higher-order metacognitive beliefs regarding the perceived impossibility of managing one’s sleep processes. This factor directly captures the paradoxical phenomenon of “sleep effort” and the distress of perceived helplessness:

• Perceived Helplessness and Loss of Autonomy: The distressing appraisal that the transition into sleep has escaped voluntary control and that one’s biological regulatory mechanisms are broken (e.g., Item 6: “I worry about my loss of control over sleep”).
• Excessive Sleep Effort: Active, counterproductive cognitive and behavioral struggle deployed to force sleep onset, which paradoxically triggers hyperarousal (e.g., Item 8: “I put great effort into trying to rectify my sleep problems”).
• Secondary Distress Over Remediation Failure: Frustration, demoralization, and panic stemming directly from the failure of sleep hygiene or relaxation techniques (e.g., Item 9: “My failure to rectify my sleep problems troubles me a lot”).
• Chronicity and Intrusiveness: The meta-awareness that sleep worry has become an unremitting, pervasive cognitive trait (e.g., Item 10: “My worry about sleep is persistent”).

Theoretical Framework

The APSQ is rooted in Harvey’s Cognitive Model of Insomnia (Harvey, 2002), which reformulated chronic sleep maintenance through the lens of cognitive psychopathology. Prior to this model, behavioral formulations (such as Spielman’s 3P Model: Predisposing, Precipitating, and Perpetuating factors) focused primarily on stimulus control, circadian alignment, and behavioral conditioning. Harvey integrated these factors into a comprehensive cognitive-behavioral feedback loop that explains how acute sleep disturbances transform into chronic, intractable insomnia.

Harvey’s model posits five core interconnected cognitive-behavioral maintenance mechanisms:

1. Excessive Presleep and Diurnal Cognitive Arousal: Patients engage in intense, repetitive negative thinking concerning their sleep deficits and daytime consequences. The APSQ directly operationalizes this node of the model.
2. Selective Attention and Monitoring: Excessive worry triggers an attentional bias wherein the individual monitors internal somatic cues (e.g., heart rate, eyelid heaviness, bodily tension) and environmental threats (e.g., bedroom noise, clocks) for signs of wakefulness or fatigue.
3. Distorted Perception of Sleep Deficits: Hyperarousal during sleep-onset leads to state misperception, where individuals systematically underestimate time spent asleep and overestimate wakefulness, reinforcing catastrophic cognitive beliefs.
4. Dysfunctional Counterproductive Safety Behaviors: In response to worry, individuals engage in behaviors intended to prevent poor sleep or manage daytime fatigue (e.g., spending excessive time in bed, taking afternoon naps, canceling obligations, forcing themselves to lie still). These safety behaviors maintain sleep disruption by destabilizing homeostatic sleep pressure and preventing disconfirmation of anxious beliefs.
5. Heightened Metacognitive Beliefs and Sleep Effort: Applying conscious intention to an involuntary, autonomic process creates a neurobiological paradox. Conscious “sleep effort” stimulates the prefrontal cortex and ascending reticular activating system, preventing the thalamocortical deactivation required for sleep.

The APSQ also integrates principles from Adrian Wells’ Metacognitive Theory and Thomas Borkovec’s Cognitive Avoidance Theory of Worry. In Wells’ framework, worry is classified into Type 1 (worry about external events or somatic states) and Type 2 (worry about worry, or metacognitive appraisal). Factor 1 of the APSQ functions predominantly as Type 1 worry (worry about daytime performance, health, and affect), whereas Factor 2 represents Type 2 metacognitive apprehension (evaluating one’s own cognitive and behavioral failure to control the sleep process). By capturing both primary worry and metacognitive distress, the APSQ provides a complete assessment of the cognitive machinery sustaining chronic insomnia.

Validity

The psychometric validity of the APSQ has been established across multiple independent clinical and community cohorts. Validation studies support construct, convergent, discriminant, and predictive validity.

Construct and Structural Validity

Initial construct validation conducted by Jansson-Fröjmark et al. (2011) utilized both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). EFA yielded a clear two-factor solution accounting for 70.7% of the total variance. Factor 1 (Consequences) accounted for 58.7% of the variance, while Factor 2 (Uncontrollability) accounted for an additional 12.0%. The correlation between the two factors was moderate to strong (r = .66, p < .001), demonstrating that while they tap distinct facets of sleep cognition, they converge on a unified higher-order construct of sleep-related cognitive preoccupation.

Convergent Validity

The APSQ shows strong, statistically significant correlations with established indices of insomnia severity, sleep-related cognitive dysfunction, and generalized psychological distress:

• Insomnia Severity Index (ISI): Strong positive correlations (r = .65 to .74, p < .001), confirming that higher levels of sleep-related worry track with diagnostic criteria for severe clinical insomnia.
• Dysfunctional Beliefs and Attitudes about Sleep (DBAS-16 / DBAS-30): Moderate-to-high correlations (r = .58 to .68, p < .001). While the DBAS measures long-standing, static cognitive schemas (e.g., “I need 8 hours of sleep to function”), the APSQ captures active, daily cognitive intrusion and acute affective preoccupation.
• Penn State Worry Questionnaire (PSWQ): Moderate positive correlations (r = .38 to .48, p < .001). This moderate magnitude confirms convergent validity with general worry constructs while demonstrating that the APSQ measures a specialized, insomnia-specific domain rather than redundant generalized trait anxiety.
• Subjective Sleep Parameters: Statistically significant correlations with sleep diary metrics, including elevated Sleep Onset Latency (SOL; r = .35 to .44), Wake After Sleep Onset (WASO; r = .30 to .41), and reduced Sleep Efficiency (SE; r = -.32 to -.45).

Discriminant Validity

Discriminant validity analyses demonstrate that the APSQ discriminates between distinct diagnostic groups. In clinical trials, one-way analyses of variance (ANOVA) followed by post-hoc comparisons showed that individuals meeting DSM-IV-TR/DSM-5 criteria for chronic insomnia scored significantly higher on the APSQ (Total Mean ≈ 65.4, SD = 18.2) than subclinical poor sleepers (Mean ≈ 42.1, SD = 16.5) and normal sleepers (Mean ≈ 18.3, SD = 9.4), with substantial effect sizes (Cohen’s d > 1.5 between insomnia and normal sleep cohorts; F-ratios > 120.0, p < .001).

Predictive and Treatment Validity

The APSQ exhibits clinical sensitivity to therapeutic change following evidence-based psychological treatment. In longitudinal trials evaluating multi-component CBT-I, APSQ total and subscale scores decreased significantly from pre-treatment to post-treatment (mean reduction of >25 points; paired t-test p < .001, Cohen’s d ranging from 1.10 to 1.45). Reductions in APSQ scores mediated improvements in daytime fatigue, psychological quality of life, and objective sleep architecture, proving its value as a process-of-change outcome measure.

Reliability

The APSQ demonstrates robust reliability across independent studies, clinical environments, and cultural adaptations.

Internal Consistency

The scale exhibits high internal consistency, avoiding excessive item redundancy. Classical psychometric evaluations by Jansson-Fröjmark et al. (2011) and subsequent replications report the following internal consistency metrics:

• Total Scale: Cronbach’s α = .93 (McDonald’s ω = .94), indicating excellent overall reliability.
• Factor 1 (Consequences): Cronbach’s α = .91, reflecting high homogeneity among items assessing somatic, affective, and cognitive consequences.
• Factor 2 (Uncontrollability): Cronbach’s α = .86, establishing solid reliability for items measuring sleep effort, uncontrollability, and persistence.
• Corrected Item-Total Correlations: Ranging between .59 and .81 across all 10 items, well above the conventional psychometric threshold of .30.

Test-Retest Reliability and Temporal Stability

In non-treatment waitlist control cohorts assessed across a 2- to 4-week interval, the APSQ exhibited high temporal stability. The intraclass correlation coefficient (ICC) was .84 (95% CI [.78, .89]), and Pearson test-retest correlation coefficients reached r = .86 (p < .001). These metrics confirm that the APSQ measures a relatively stable cognitive trait in the absence of therapeutic intervention, while remaining sensitive to clinical change during active treatment.

Standard Error of Measurement and MDC

The Standard Error of Measurement (SEM) for the APSQ has been calculated at approximately 4.82 points on the 10–100 scale. The corresponding Minimal Detectable Change (MDC at the 95% confidence level, calculated as $MDC_{95} = SEM \times 1.96 \times \sqrt{2}$) is approximately 13.36 points. A patient exhibiting a score reduction greater than 14 points following CBT-I can be reliably classified as having experienced true cognitive change beyond measurement error.

Factor Analysis

The dimensional structure of the APSQ has been investigated via exploratory factor analysis (EFA) with principal axis factoring and oblique (Promax/Olimin) rotations, followed by confirmatory factor analysis (CFA) using maximum likelihood estimation with robust standard errors (MLR).

Exploratory Factor Analysis (EFA) Findings

Initial factor extractions across clinical and community samples (Jansson-Fröjmark et al., 2011) confirmed the appropriateness of the correlation matrix for factor analysis (Kaiser-Meyer-Olkin measure of sampling adequacy = .92; Bartlett’s Test of Sphericity χ² = 1842.6, p < .001). Scree plot inspection and Kaiser’s eigenvalue-greater-than-one criterion revealed a two-factor structure accounting for 70.7% of total variance:

• Factor 1: Worries About the Consequences of Poor Sleep (Eigenvalue = 5.87, accounting for 58.7% of variance). Items loading on this factor: Item 1 (.64), Item 2 (.85), Item 3 (.81), Item 4 (.88), Item 5 (.83), and Item 7 (.79).
• Factor 2: Worries About the Uncontrollability of Sleep (Eigenvalue = 1.20, accounting for 12.0% of variance). Items loading on this factor: Item 6 (.66), Item 8 (.79), Item 9 (.84), and Item 10 (.72).
• Cross-Loadings: Cross-loadings across alternative factors were minimal (≤ .24), demonstrating clean factor separation.

Confirmatory Factor Analysis (CFA) Fit Indices

Confirmatory factor modeling comparing a unidimensional single-factor model against the theoretical two-factor correlated model demonstrated the superiority of the two-factor specification. The table below outlines model fit indices derived from structural equation modeling across validation cohorts:

Fit criteria (χ²/df < 3.0, Comparative Fit Index [CFI] ≥ .95, Tucker-Lewis Index [TLI] ≥ .95, Root Mean Square Error of Approximation [RMSEA] ≤ .06, and Standardized Root Mean Square Residual [SRMR] ≤ .05) demonstrate that the two-factor model provides an excellent fit to empirical data, supporting the psychological distinction between consequence-focused worry and uncontrollability/sleep effort.

Instrument / Measurement Tool

The APSQ is structured as an efficient, self-administered rating instrument that evaluates the frequency and perceived truth of intrusive sleep cognitions over the preceding month.

• Instrument Designation: Anxiety and Preoccupation about Sleep Questionnaire (APSQ)
• Diagnostic Classification: Psychological self-report rating scale / Cognitive assessment tool
• Format: Paper-and-pencil or secure computer-based digital questionnaire
• Item Count: 10 discrete declarative statements
• Response Format: 10-point continuous numerical Likert-type rating scale, anchored from 1 (Not true) to 10 (Very true)
• Time Reference Window: “During the past month”
• Administration Time: Approximately 2 to 3 minutes
• Target Population: Adults (aged 18+) presenting with primary or comorbid insomnia, circadian rhythm disorders, generalized anxiety disorder with sleep complaints, or secondary sleep disruptions associated with chronic medical or psychiatric conditions. Also validated in adolescent and young adult cohorts (ages 16+).
• Scoring Methodology:
  • Total Score Calculation: Derived by summing the responses across all 10 items. Theoretical range: 10 to 100. Alternatively, clinicians may compute a mean item score ranging from 1.0 to 10.0. Higher scores reflect elevated sleep-related cognitive preoccupation, hyperarousal, and perceived helplessness.
  • Factor 1 Subscale (Worries about Consequences): Sum of Items 1, 2, 3, 4, 5, and 7. Range: 6 to 60.
  • Factor 2 Subscale (Worries about Uncontrollability): Sum of Items 6, 8, 9, and 10. Range: 4 to 40.
• Clinical Interpretation Guidelines:
  • Score < 30: Minimal / Subclinical sleep-related worry. Characteristic of healthy, normal sleepers without cognitive sleep intrusion.
  • Score 30 to 49: Mild to moderate sleep preoccupation. Commonly observed in subclinical poor sleepers, situational adjustment insomnia, or resolving chronic insomnia.
  • Score 50 to 69: Clinically significant sleep-related anxiety. Typical threshold for clinical chronic insomnia; indicative of substantial cognitive arousal requiring cognitive restructuring.
  • Score ≥ 70: Severe cognitive hyperarousal and preoccupation. Severe metacognitive distress, high sleep effort, and strong risk of treatment resistance without targeted cognitive intervention.

Permissions & Fee and Test Year

The Anxiety and Preoccupation about Sleep Questionnaire was initially developed in 2004 by Nicole K. Y. Tang and Allison G. Harvey within experimental insomnia protocols, with full independent psychometric scale validation published in 2011 by Markus Jansson-Fröjmark, Allison G. Harvey, Lars-Gunnar Lundh, Annika Norell-Clarke, and Steven J. Linton.

Copyright and Usage Permissions: The APSQ is an open-access psychometric instrument for academic research, non-profit scientific investigation, and individual clinical practice. The authors and copyright holders grant permission for clinical psychologists, physicians, and behavioral scientists to administer, score, and evaluate the scale without royalty fees or licensing costs, provided proper citation of the original validation studies is maintained. Commercial distribution, proprietary integration into fee-for-service software platforms, or publication within for-profit diagnostic assessment batteries requires written permission from the copyright holders and original authors.

References

• Harvey, A. G. (2002). A cognitive model of insomnia. Behaviour Research and Therapy, 40(8), 869–893. https://doi.org/10.1016/S0005-7967(01)00061-6
• Jansson-Fröjmark, M., Harvey, A. G., Lundh, L. G., Norell-Clarke, A., & Linton, S. J. (2011). Psychometric properties of an insomnia-specific measure of worry: The Anxiety and Preoccupation about Sleep Questionnaire. Cognitive Behaviour Therapy, 40(1), 65–76. https://doi.org/10.1080/16506073.2010.538433
• Morin, C. M., Vallières, A., & Ivers, H. (2007). Dysfunctional beliefs and attitudes about sleep (DBAS): Validation of a brief version (DBAS-16) and its relationship to insomnia severity, treatment outcome, and response to therapy. Sleep, 30(9), 1151–1158. https://doi.org/10.1093/sleep/30.9.1151
• Tang, N. K. Y., & Harvey, A. G. (2004). Correcting distorted perception of sleep in insomnia: A novel behavioural experiment? Behaviour Research and Therapy, 42(1), 27–39. https://doi.org/10.1016/S0005-7967(03)00068-X
• Wells, A. (2000). Emotional disorders and metacognition: Innovative cognitive therapy. John Wiley & Sons.

Items of the Scale