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    1 Comment for this article
    DSM-IV and DSM-IV-TR: No Changes in Diagnostic Criteria
    Richard M. Glass, MD | Dept. of Psychiatry and Behavioral Neuroscience, University of Chicago
    The article by Edinger et al1 provided valuable information about the reliability and validity of insomnia diagnoses. However, the use of the terms “DSM-IV-TR diagnoses“ and “DSM-IV-TR nosolology” was misleading in implying that the diagnostic criteria included in the 2000 DSM-IV-TR2 publication differed from or were updated from those published in the 1994 publication of DSM-IV.3 In fact the 2000 DSM publication revised only descriptive textual material and did not change either the classification system or the dignostic criteria published in 1994. As noted in the DSM-IV-TR introduction, “No substantive changes in the criteria sets were considered, nor were any proposals entertained for new disorders, new subtypes, or changes in the status of the DSM-IV appendix categories” (page xxix). The fact that the DSM nosology and diagnostic criteria for psychiatric disorders have not changed since 1994 highlights the importance of the changes being planned for DSM-5. Richard M. Glass, MD Contributing Editor, JAMA Clinical Professor, Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, Illinois
    1. Edinger JD, Wyatt JK, Stepanski EJ, Olsen MK, Stechuchak KM, Carney CE, Chiang A, et al. Testing the reliability and validity of DSM-IV-TR and ICSD-2 insomnia diagnoses: results of a multitrait-multimethod analysis. Arch Gen Psychiatry. 2011.68(10)992-1002.
    2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disdorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.
    3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disdorders. 4th ed. Washington, DC: American Psychiatric Association; 1994

    Conflict of Interest: None declared
    Original Article
    Oct 2011

    Testing the Reliability and Validity of DSM-IV-TR and ICSD-2 Insomnia Diagnoses: Results of a Multitrait-Multimethod Analysis

    Author Affiliations

    Author Affiliations: Veterans Affairs Medical Center (Drs Edinger, Olsen, and Means and Ms Stechuchak) and Duke University Medical Center (Drs Edinger, Olsen, Chiang, Lineberger, Means, Radtke, and Krystal), Durham, North Carolina; Sleep Disorders Service and Research Center, Department of Behavioral Sciences, Rush University Medical Center, Chicago, Illinois (Drs Wyatt and Crisostomo); ACORN Research, LLC, Memphis, Tennessee (Dr Stepanski); Ryerson University, Toronto, Ontario, Canada (Dr Carney); and Veterans Affairs Medical Center, Miami, Florida (Dr Wohlgemuth).

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

    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.