Testing the reliability and validity of DSM-IV-TR and ICSD-2 insomnia diagnoses. Results of a multitrait-multimethod analysis

Arch Gen Psychiatry. 2011 Oct;68(10):992-1002. doi: 10.1001/archgenpsychiatry.2011.64. Epub 2011 Jun 6.


Context: Distinctive diagnostic classification schemes for insomnia diagnoses are available, but the optimal insomnia nosology has yet to be determined.

Objectives: To test the reliability and validity of insomnia diagnoses listed in the American Psychiatric Association's DSM-IV-TR and the International Classification of Sleep Disorders, second edition (ICSD-2).

Design: Multitrait-multimethod correlation design.

Setting: Two collaborating university medical centers, with recruitment from January 2004 to February 2009.

Participants: A total of 352 adult volunteers (235 of whom were women) who met research diagnostic criteria for insomnia disorder.

Main outcome measures: Goodness-of-fit ratings of 10 DSM-IV-TR and 37 ICSD-2 insomnia diagnoses for each patient. Ratings were provided by 3 clinician pairs who used distinctive assessment methods to derive diagnostic impressions. Correlations computed within and across clinician pairs were used to test reliability and validity of diagnoses.

Results: Findings suggested that the best-supported DSM-IV-TR insomnia categories were insomnia related to another mental disorder, insomnia due to a general medical condition, breathing-related sleep disorder, and circadian rhythm sleep disorder. The category of primary insomnia appeared to have marginal reliability and validity. The best-supported ICSD-2 categories were the insomnias due to a mental disorder and due to a medical condition, obstructive sleep apnea, restless legs syndrome, idiopathic insomnia, and circadian rhythm sleep disorder-delayed sleep phase type. Psychophysiological insomnia and inadequate sleep hygiene received much more variable support across sites, whereas the diagnosis of paradoxical insomnia was poorly supported.

Conclusions: Both the DSM-IV-TR and ICSD-2 provide viable insomnia diagnoses, but findings support selected subtypes from each of the 2 nosologies. Nonetheless, findings regarding the frequently used DSM-IV-TR diagnosis of primary insomnia and its related ICSD-2 subtypes suggest that their poor reliability and validity are perhaps due to significant overlap with comorbid insomnia subtypes. Therefore, alternate diagnostic paradigms should be considered for insomnia classification.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Diagnostic and Statistical Manual of Mental Disorders*
  • Female
  • Humans
  • International Classification of Diseases* / standards
  • Interviews as Topic
  • Male
  • Medical Records
  • Middle Aged
  • Observer Variation
  • Polysomnography
  • Reproducibility of Results
  • Sleep
  • Sleep Initiation and Maintenance Disorders / classification
  • Sleep Initiation and Maintenance Disorders / diagnosis*
  • Sleep Initiation and Maintenance Disorders / psychology