Comparative Strengths and Weaknesses of DSM-5-TR and ICD-11 for Diagnosing Insomnia Disorder
DSM-5-TR Strengths
The DSM-5-TR provides a streamlined, clinically practical diagnostic framework that emphasizes functional impairment and is well-suited for psychiatric practice settings. 1
Clear frequency and duration thresholds – The DSM-5-TR specifies insomnia occurring ≥3 nights per week for ≥3 months, providing quantitative criteria that reduce diagnostic variability and improve inter-rater reliability 1, 2
Emphasis on daytime consequences – The system requires documentation of clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning, ensuring that only clinically meaningful cases are diagnosed 1, 3
Simplified comorbidity approach – DSM-5-TR moved away from the problematic "primary" versus "secondary" insomnia distinction, recognizing insomnia as a disorder in its own right that warrants independent clinical attention even when co-occurring with other conditions 4, 5
High clinical utility in psychiatric settings – Field trials demonstrated that "Insomnia related to another mental disorder" (44% of cases) and "Primary insomnia" (20.2% of cases) were the most frequently assigned DSM-IV diagnoses, showing good clinical uptake 6
Strong validity for specific subtypes – Research supports the reliability and validity of DSM-IV-TR categories including insomnia related to another mental disorder, insomnia due to a general medical condition, breathing-related sleep disorder, and circadian rhythm sleep disorder 7
DSM-5-TR Weaknesses
Poor reliability of "Primary Insomnia" construct – Multitrait-multimethod analysis revealed that the DSM-IV-TR diagnosis of primary insomnia had only marginal reliability and validity, likely due to significant overlap with comorbid insomnia subtypes 7
Limited phenotypic specificity – The DSM-5-TR does not distinguish between sleep-onset, sleep-maintenance, and early-morning awakening subtypes, which have different treatment implications and may represent distinct pathophysiological mechanisms 1, 4
Insufficient guidance on objective measures – The system relies almost exclusively on self-report and does not integrate polysomnography, actigraphy, or sleep diary data into diagnostic criteria, despite their research importance 4, 5
Lack of severity gradations – DSM-5-TR does not provide standardized severity ratings (mild, moderate, severe) based on frequency of nights affected per week or degree of daytime impairment 1
Minimal attention to perpetuating factors – The diagnostic criteria do not systematically assess maladaptive sleep behaviors, dysfunctional beliefs about sleep, or conditioned arousal—all critical targets for cognitive-behavioral therapy 1
ICD-11 Strengths
The ICD-11 offers a globally applicable, harmonized classification system that balances clinical utility with public health surveillance needs. 1
International standardization – As the WHO's official classification system implemented by member states from January 2022, ICD-11 ensures consistent diagnostic coding across healthcare systems worldwide for epidemiological tracking and resource allocation 1
Harmonization with DSM-5 – The WHO and American Psychiatric Association collaborated to align ICD-11 and DSM-5 structures, reducing diagnostic discordance between the two most widely used systems 1
Separation of sleep-wake disorders chapter – ICD-11 created a dedicated sleep-wake disorders chapter (cross-listed from the Mental, Behavioral or Neurodevelopmental Disorders chapter), improving visibility and facilitating multidisciplinary care 1
Developmental continuity emphasis – ICD-11 eliminated the separate "disorders with onset in childhood/adolescence" grouping, recognizing that insomnia and other sleep disorders show continuity across the lifespan 1
Dimensional additions to categorical diagnoses – ICD-11 introduced a stepwise diagnostic approach for some categories that incorporates both categorical and dimensional elements, potentially improving clinical utility for different user groups 1
ICD-11 Weaknesses
Modest changes from ICD-10 – The transition from ICD-10 to ICD-11 involved relatively conservative modifications, maintaining a predominantly categorical symptom-based approach rather than incorporating neurobiology-based or hierarchical classification paradigms 1
Limited insomnia-specific detail – Like DSM-5-TR, ICD-11 does not provide the granular subtyping found in the International Classification of Sleep Disorders (ICSD-2), which lists 12 specific insomnia disorders with distinct clinical features 1
Insufficient operationalization – ICD-11 does not specify the quantitative severity thresholds (e.g., sleep latency >31 minutes) that research has identified as optimal for distinguishing clinical insomnia from normal sleep variability 2
Lack of integration with sleep medicine nosology – The ICSD-2 categories (psychophysiological insomnia, paradoxical insomnia, idiopathic insomnia, inadequate sleep hygiene) provide clinically useful distinctions that are not captured in ICD-11's broader framework 1, 7
Variable field performance – Research using ICSD-2 diagnoses showed that psychophysiological insomnia and inadequate sleep hygiene received variable support across clinical sites, while paradoxical insomnia was poorly supported, suggesting that even more detailed systems face reliability challenges 7
Comparative Analysis: Which System to Use in Clinical Practice
For routine psychiatric and primary care practice, DSM-5-TR provides the most practical diagnostic framework, while ICSD-2 (referenced in sleep medicine guidelines) offers superior phenotypic detail for treatment planning. 1
Clinical settings – Use DSM-5-TR criteria (≥3 nights/week for ≥3 months with daytime impairment) for initial diagnosis and insurance coding, as this aligns with evidence-based treatment guidelines recommending CBT-I as first-line therapy 1, 3
Sleep medicine specialty practice – Apply ICSD-2 subtypes (psychophysiological insomnia, paradoxical insomnia, idiopathic insomnia, insomnia due to mental disorder, insomnia due to medical condition, insomnia due to drug/substance, inadequate sleep hygiene) to guide specific behavioral and pharmacological interventions 1
Research contexts – Employ quantitative criteria validated by Lichstein et al.: sleep latency or wake after sleep onset ≥31 minutes, occurring ≥3 nights/week, for ≥6 months, as these thresholds optimize sensitivity-specificity balance 2
International epidemiology – Use ICD-11 coding for public health surveillance and cross-national comparisons, recognizing its role as the global standard for morbidity and mortality statistics 1
Critical Diagnostic Pitfalls to Avoid
Over-reliance on the "primary insomnia" label – This DSM-IV-TR construct showed poor reliability and validity in field trials; instead, identify and treat comorbid conditions (present in >75% of insomnia patients) while recognizing insomnia as warranting independent clinical attention 7, 6
Failing to assess specific insomnia phenotypes – Sleep-onset versus sleep-maintenance versus early-morning awakening patterns have different pharmacological implications (e.g., zaleplon for onset, doxepin for maintenance, eszopiclone for combined) that neither DSM-5-TR nor ICD-11 adequately capture 1, 3, 8
Neglecting perpetuating factors – Neither system systematically evaluates maladaptive behaviors (excessive time in bed, irregular sleep schedules), dysfunctional cognitions ("I must get 8 hours or I'll be ruined"), or conditioned arousal (bed = frustration), all of which are critical CBT-I targets 1
Ignoring objective-subjective discordance – Paradoxical insomnia (severe subjective complaint with minimal objective sleep disturbance) requires different management than psychophysiological insomnia, but DSM-5-TR and ICD-11 do not distinguish these presentations 1
Premature diagnosis without adequate assessment – A 2-week sleep diary documenting bedtime, sleep latency, number and duration of awakenings, wake after sleep onset, time in bed, total sleep time, and sleep efficiency is essential before finalizing any insomnia diagnosis 1, 3
Missing comorbid sleep disorders – Insomnia persisting beyond 7-10 days of treatment warrants evaluation for obstructive sleep apnea, restless legs syndrome, periodic limb movement disorder, or circadian rhythm disorders—conditions that both DSM-5-TR and ICD-11 list separately but that frequently co-occur with insomnia 1, 3