Am J Psychiatry 1991; 148:432-438
Copyright © 1991 by American Psychiatric Association
Subtyping DSM-III-R primary insomnia: a literature review by the DSM-IV Work Group on Sleep Disorders
CF Reynolds 3d, DJ Kupfer, DJ Buysse, PA Coble and A Yeager
Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, PA 15213.
OBJECTIVE: The authors review the usefulness, reliability, and validity of
recently proposed subtypes of primary insomnia. DSM-III uses "primary
insomnia" to indicate chronic insomnia not associated with other
diagnosable mental or medical disorders, whereas the International
Classification of Sleep Disorders (ICSD) recognizes three subtypes:
psychophysiological insomnia, idiopathic insomnia, and sleep state
misperception. METHOD: After reviewing all of the primary source references
for each insomnia disorder in the ICSD and all of the additional primary
sources cited in each of these, the authors conducted an automated
literature search using Medline. Of the 48 primary sources located, the
authors selected 27 studies that were reported in peer-reviewed journals,
had the largest available subject groups, used diagnostic reliability
procedures, and included control groups. RESULTS: The studies reviewed
contained limited empirical support for the proposed distinction between
idiopathic and psychophysiological insomnia. Sleep state misperception
appears, however, to be a highly prevalent feature of chronic insomnia
generally, rather than only a specific disorder per se. CONCLUSIONS: The
authors conclude that there is not yet sufficient empirical evidence to
warrant the abandonment of DSM-III-R "primary insomnia" and the adoption of
the ICSD subtypes in DSM-IV. However, they affirm the heuristic value of
the ICSD subtypes and the need for field trials to compare the performance
characteristics of the DSM-III-R and ICSD systems with respect to 1)
interrater reliability, 2) effects of rater expertise (generalist versus
specialist) on rates of agreement, and 3) effects of polysomnographic data
on rates of agreement.
