www.crossingdialogues.com/journal.htm ORIGINAL ARTICLE Crossing Dialogues Association How interested in classifi cation are British and American psychiatrists and how have they chosen to study it over the last 50 years? MARK GRIFFITHS Consultant Child and Adolescent Psychiatrist; Newport, South Wales (UK) Aims and Methods: The general conceptual issues involved in psychiatric classifi cation seem to be increasingly neglected in contrast to a focus on specifi c and empirical aspects which appear to have come to dominate the study of classifi cation in the fi eld. This article explores how the psychiatric fi eld (in the UK and US) has chosen to analyse classifi cation over time. Publication trends of articles in both The American Journal of Psychiatry and The British Journal of Psychiatry over a fi fty year period (1960-2010) can be viewed as indicators of the levels of interest within the psychiatric fi eld toward classifi cation. In an exploratory analysis, articles explicitly focusing on classifi cation were counted and further sub-divided according to whether they focused on empirical or conceptual aspects and whether they adopted a general perspective or focused on a more specifi c aspect of classifi cation. Results: Interest in classifi cation was apparent in a minority of published articles (4.7% of all published articles). Interest in conceptual aspects dropped throughout the fi fty years and was found to be considerably less than for empirical approaches which steadily increased over time. General papers about classifi cation have been gradually on the decline and have been increasingly outnumbered by more specifi cally-focused articles. Clinical Implication: Classifi cation, as a foundational endeavour within the psychiatric fi eld, requires increased attention in the literature. This literature should address conceptual as well as empirical issues. Keywords: Psychiatric Classifi cation, Conceptual Research, Philosophy of Psychiatry, Bibliometric Research DIAL PHIL MENT NEURO SCI 2013; 6(1): 23-33 23 INTRODUCTION For the purposes of this paper it is taken as self-evident that any discipline benefi ts from thorough and critical self-examination. How the psychiatric fi eld examines itself, which will include what perspectives it favours to accomplish this at different points in time, is one of the issues explored in this paper. It will focus, in particular, on how the profession has gone about analysing classifi cation and the survey aims to provide some degree of measure as to how interested psychiatrists have been about this endeavour over time in both the UK and America. Psychiatric classifi cation, in particular in relation to reliability and validation issues, appears to have become dominated by an empirical approach with a relative neglect of conceptual issues (Kirk and Kutchins, 1992, 1997; Wiggins and Schwartz, 1994; Mace, 2002; Pincus and McQueen, 2002; Cooper, 2004; Harre, 2004; Bracken and Thomas, 2005; Fulford et al, 2006; Kendler et al, 2008; Philips, 2009; Schaffner, 2010). This "empirical turn" has been acknowledged by a range of eminent nosologists in the fi eld (Robins and Guze, 1970; Kendler, 1990; Jensen and Hoagwood, 1997; Hyman, 2002; Kendall, 2002; Kupfer et al, 2002; Kendall and Jablensky, 2003; First and Pincus, 2004; Regier et al, 2005, 2009; Moller, 2008) and philosophers of psychiatry (Fulford, 1994; Wiggins and Schwartz, 1994; Sadler, 2005; Fulford et al, 2006; Cooper, 2008; Zachar and Kendler, 2007; Schaffner, 2010). One of the intriguing but complicating realities is that psychiatry is at the interface of many disparate fi elds (Sadler and Fulford, 2004). One important, but often neglected, area of such inter-connected study is philosophy with its focus on a range of conceptual issues. In order to clarify what "conceptual" is taken to mean for the purposes of this paper a short summary of the conceptual research context is presented: Conceptual issues at the level of scientifi c methodology. That there are a range of conceptual issues which need examining before a full picture of science is achieved has been increasingly recDialogues in Philosophy, Mental and Neuro Sciences DIAL PHIL MENT NEURO SCI 2013; 6(1): 23-33 Griffi ths ognized by philosophers of science over the last half century (Kuhn, 1996; Longino, 1990; Okasha, 2002). The literature emerging from, the relatively new, sub-discipline of philosophy of psychiatry reveals that the sciences underpinning psychiatry are more diffi cult, both conceptually and empirically, than physical medicine (Fulford, 1994; Wiggins and Schwartz, 1994; Okasha, 2002; Kendler, 2005; Sadler, 2005; Fulford et al, 2006; Bolton, 2008; Cooper, 2008; Jablensky, 2010). The most persuasive of many attempts to develop a conceptually sound version of the traditional common-sense picture of science is termed by the leading philosopher of psychiatry, Bill Fulford, as logical empiricism (Fulford et al, 2006). Its claims include a clear methodology of what science is and what demarcates it from non-science activity. It pre-supposes a range of epistemological and ontological assumptions (Fulford, 1994; Sadler, 2005; Zachar and Kendler, 2007; Cooper, 2008). An associated belief is that observations can successfully be separated from theory giving reason to believe in scientifi c objectivity (Hempel, 1961; Fulford et al, 2006; Cooper, 2008). Post-logical empiricists, the group of more critical philosophers of science, have contended that a determined and rigorous attempt to identify the essential features of scientifi c method has ultimately failed to provide a full and fi nal characterisation of what science is about (Wallace, 1994; Fulford et al, 2006; Cooper, 2008). The theory-independence of observations has been challenged from within this paradigm (Cooper, 2004, 2008). A range of other biasing subjective factors have been described as being inevitable in psychiatric science, e.g. beliefs and choices about what is selected to study and the infl uence of a range of epistemic and non-epistemic values (Margolis, 1994; Wallace, 1994; Sonuga-Barke, 2011). As a result, a conceptually-unproblematic "common sense" view of science is not considered tenable by many (Kendler, 1990; Mishara, 1994; Fulford et al, 2006; Cooper, 2008). The philosopher of science Longino (1990) suggested that what scientists take for granted should be rendered explicit and critically examined by philosophers. Ken Kendler (2005) expresses the need to "establish a methodologically rigorous but conceptually open-minded scientifi c playing fi eld" (p.438). Within mainstream psychiatric classifi cation alongside the types of assumptions discussed above John Sadler (2005) has carried out a values analysis on DSM-IV and shown that it includes 24 different types of value judgements. These were mainly hidden and unacknowledged with only six explicitly fore-grounded in the manual. Conceptual aspects of classifi cation. Whether psychiatric classifi cations are forms of natural classifi cations ("carving nature at it's joints") or artifi cial classifi cations (useful for us but only expressing our perceptions of the world but not necessarily capturing, or discovering, what it really is like) has been debated in the literature (Kendall, 1975; Kendler, 1990; Margolis, 1994; Wiggins and Scwartz, 1994; Jensen and Hoagwood, 1997; Kutchins and Kirk, 1997; Kendall and Jablensky, 2003; Jablensky, 2005, 2010; Fulford et al, 2006; Zachar and Kendler, 2007; Moller, 2008). Making such distinctions is not straightforward and neither is it given to us by the process of science alone-it involves the theory-laden interpretations and conceptual fi lters of human beings with their unavoidably selective interest in how they divide up the world (Cooper, 2004). Classifi ers inherently have a priori concepts about the things they are classifying, and the nature and goals of those classifi cations (Margolis, 1994; Kendler, 2005). Classifi cation within psychiatry has been shown to be inherently more conceptual than it is for the rest of medicine (Sadler, 2005; Fulford et al, 2006). Some nosologists and philosophers argue that there is a crucial need for conceptual analysis of psychiatric classifi cation in order to excavate the conceptual artefacts of our taxonomies, ask what these artefacts teach us and evaluate whether the artefacts are worth keeping (Sadler et al, 1994; Wallace, 1994; Sadler, 2005). Conceptual aspects of validity. Validity is a multi-faceted variably defi ned concept. It has philosophical and logical meanings but in empirical science it is related to the extent of "capture" of the reality of nature (Schaffner, 24 www.crossingdialogues.com/journal.htm 2010). Much consideration of notions of validity in psychiatry stem from the concept's use in the psychometric fi eld (Cronbach and Meehl, 1955). Contemporary discussions and research into validity have been heavily infl uenced by the 1970 paper by Robins and Guze which articulated an essentially empirical approach to ascertaining the validity of psychiatric disorders. Their methodology has undergone some modifi cations over the last 40 years but essentially the framework remains the same (Kendler, 1990; Kupfer et al, 2002; Kendall and Jablensky, 2003; Regier et al, 2009; Schaffner, 2010). That validity in psychiatry is not simply a matter resolved one way or the other by appeal to empirical psychiatric science has been discussed by philosophers of science (Fulford et al, 2006; Schaffner, 2009, 2010; Zachar, 2010) and leading psychiatric nosologists (Pincus and McQueen, 2002; Kendall and Jablensky, 2003; Kendler et al, 2008; Moller, 2008; First, 2010; Jablensky, 2010; Kendler and First, 2010). The concept of validity is fundamentally philosophical in nature (Schaffner, 2010; Zachar, 2010). Bill Fulford (2006) argues that an "extended family" of validities appropriate to our fi eld is required to do justice to the complexity and diffi culties inherent in "doing" psychiatric science. Ken Kendler (1990) acknowledges that the choice between different empirical validators – i.e., what "counts" more when attributing a "valid" disorder status (e.g., course/prognosis, description of clinical picture, aetiology or treatment response) – is a fundamentally conceptual matter. Others consider that a hierarchy of validity currently exists within our classifi cation systems (Wiggins and Schwartz, 1994). Since the publication of a seminal article by Kendall and Jablensky in 2003 debate about what constitutes validity has become increasingly problematized. They set out rigorous criteria (both conceptual and empirical) to establish the validity of psychiatric disorder constructs and classifi cation systems in general. In their terms no current psychiatric condition or classifi cation system has a right to claim validity but, they argue, should mostly be retained if they can demonstrate that they provide clinical utility for clinicians and researchers. Clinical utility as a concept has since been used in various contexts conferring it with different meanings. Kendall and Jablensky saw it as little more than a heuristic devise to guide therapeutic endeavor, Robert Spitzer confl ated it with validity ( Pincus, 2010 ), whereas First and Pincus (2004) have adopted what they consider to be the middle ground conceptualization of the term. Future conceptual directions for the study of validity have been advocated by a number of authors (Stoyanov, 2009; Kendler and First, 2010). The conceptual aspects of the "objects" of psychiatric classifi cation. All the "objects" of interest to psychiatric classifi ers are concepts which are generally elusive to clear defi nitions, harbour tacit assumptions and often have contested histories within the fi eld of psychiatry (Fulford, 1994; Wallace, 1994; Ross, 2002; Widiger, 2002; Sadler, 2005): e.g., "symptom", "behaviour" "function / dysfunction", etc. They are far from self-evident facts of commonsense perception and require explication by conceptual analysis (Sadler, 2005; Fulford et al, 2006). A major diffi culty arises since the main "object" of interest to classifi cation is, in fact, a "subject", with all the complex conceptual "baggage" that this carries! (Mishara, 1994; Harre, 2003) A central "object" of interest for psychiatry is the concept "mental disorder". It has been analyzed from a range of conceptual perspectives (Bolton, 2008). An ontological approach has led to much debate amongst philosophers(Schwartz and Wiggins, 1987; Hacking, 1998; Zachar, 2000; Haslam, 2002; Cooper, 2004). They have asked "what kinds of thing" are mental disorders? The resulting literature reveals that mental disorders resist, for a range of reasons, clear-cut conceptualization as "natural kinds" (Zachar, 2000) (naturally occurring disease entities) but that some might feasibly qualify as such, under certain conditions (Cooper, 2004).There are a number of biomedical model theories that attempt to account, in naturalistic terms, for mental disorders (Zachar and Kendler, 2007; Bolton, 2008; Cooper, 2008). The theories involved are fundamentally conceptual in nature with regard to the decisions involved in adopting one theory over another (Fulford et al, 2006). Some philosophers contend that most mental disorders should be considered "practical kinds" (Zachar, 25 DIAL PHIL MENT NEURO SCI 2013; 6(1): 23-33 Griffi ths 2000) ( kinds that it is useful to pick out for some purposes but there is no qualitatively objective discontinuity to be discovered), whilst others are even more nominalistic stating that mental disorders are "interactive kinds" (Hacking, 1998) (i.e.,interact with what they classify). Haslam (2002) concludes that given the heterogeneity of conditions regarded as mental disorders, with their accompanying range of diverse conceptual features, there is good reason to divide them into a number of ontological kinds. More critical sociological perspectives include the consideration that mental disorders are more akin to "moral kinds" (Foucault, 1961/1965) or as "artifi cial kinds" (Szasz, 1961) that fundamentally do not involve legitimate scientifi c judgements (Kutchins and Kirk, 1997). Other critics view mental disorders as inappropriate medicalizing conceptualizations of social deviance (Scheff, 1966) or merely social constructions (Gergen, 1991) that should be privileged no more than any other way of constructing an individual's diffi culties. From a taxonomical perspective the myriad inherent conceptual diffi culties involved has divided the beliefs of classifi ers who struggle to be clear what form of classifi cation does justice to the complex phenomena of interest to the psychiatric fi eld (Pichot, 1994; Wallace, 1994; Wiggins and Schwartz, 1994; Jensen and Hoagwood, 1997; Widiger, 2002; Jablensky, 2005; Moller, 2008). Faithful logical empiricists with their naturalistic dispositions, essentialist outlooks and scientifi c realist assumptions have no diffi culty speaking in terms of a nosological classifi cation (Hyman, 2002; Kupfer et al, 2002; Regier et al, 2005, 2009) (i.e., focusing on clearly distinct and understood diseases) with the main conceptual issues of note being the need to decide between a categorical or a dimensional approach and establishing the most appropriate empirical validating methodology. Those sympathetic to the assumptions of one of the versions of the biomedical paradigm , but who are more circumspect about the disease-status of what are described as mental disorders recommend viewing our classifi cation as a syndromatology (Kendall, 1989; Moller, 2008) (clusters of related symptoms with characteristic time-course but with unclear causation and "discreteness"). Some critics from within the fi eld consider that, at best, we have a typology ("types" don't really exist but arise through abstraction of real facts – delineating defi nitions are, as a result, characteristically blurred) of mental disorders (Moller, 2008). Others have made claims that our classifi cations should not be based on anything as grandiose as a valid nosology but on various constructs of a more nominalistic nature such as "ideal types" (Schwartz and Wiggins, 1987), "fuzzy concepts" (Agich, 1994), "family resemblances"(Blashfi eld et al, 1989) and "prototypes"(Margolis, 1994). From yet another perspective, a more linguistic-focused analysis of the concept of mental disorder raises the possibility that mental disorder is a classifi catory metaphor (Pickering, 2005). Values scholars have explicated the intrinsic evaluative nature of ascribing to a condition of interest "disorder" status (Agich, 1994; Fulford, 1994; Ross, 2002; Widiger, 2002; Sadler, 2005; Bolton, 2008). Once this decision is made the biomedical discourse appears relevant (e.g., couching associated features in the terms of "cause", "course" and "treatment"). In essence, the disorder-like features of the conditions in question do not appear independently of their classifi cation as disorders. Ludwig Wittgenstein had this kind of tautological concern in mind when he stated: "Show me how you are searching and I will tell you what you are looking for" (Wittgenstein, 1953). SURVEY The methodology, described below, is largely justifi ed by the arguments put forward by Kecmanovic and Hadzi-Pavlovic (2010) who carried out a similar survey. They examined the publication trends of both the American Journal of Psychiatry (AJP) and British Journal of Psychiatry (BJP) over 60 years to explore conceptual orientation of the psychiatric fi eld in the respective countries of journal origin. They clearly set out in detail the rationale for choosing these two journals as being representative, at any given time, of the professions' attitudes, conceptual orientations and interest in various topics. A review of the literature focusing on the history of psychiatric classifi cation (See table I for a summary of multiple perspectives on the historical context), over the last fi fty years, sug26 www.crossingdialogues.com/journal.htm 27 Ta bl e 1: L ite ra tu re re vi ew o f h is to ric al c on te xt s f ro m v ar io us re le va nt p er sp ec tiv es w ith re ga rd s p sy ch ia tri c cl as si fi c at io n 19 60 s 19 70 s 19 80 s 19 90 s 20 00 s P hi lo so ph y G en er al T re nd s (1 -3 ) T he 'l in gu is tic tu rn ' i n U K & U S M os t Eu ro pe an c ou nt rie s T he 'P os t-M od er n Tu rn ' i nfl u en ce d p hi lo so ph y in m id 2 0t h c en tu ry d om in at ed b y 'C on tin en ta l U K / U S ph ilo so ph y bu t n ot to th e ex te nt l ed to d om in an ce o f t he tr ad iti on s Ph ilo so ph y' sc ho ol s it h as in E ur op e o f A na ly tic & P ra gm at ic P hi lo so ph ie s ( Ex is te nt ia lis m ; P he no m en ol og y ( Po st -S tru ct ur al is m ; D ec on st ru ct io n H er m en eu tic s; S tru ct ur al is m ) D

is tru st o f ' m et ana rr at iv es ' ) Ph ilo so ph y of Sc ie nc e (1 -3 ) Lo gi ca l E m pi ric is m In fl u en ce o f T ho m as K uh n' s ( 1 96 2 ) In cr ea si ng ly L og ic al E m pi ric is t & P op pe r's C rit ic al 'S tru ct ur e of S ci en tifi c R ev ol ut io ns ' A cc ou nt s c om pe te w ith a b ro ad R at io na lis m d om in an t I nc re as es th ro ug ho ut 1 97 0s & 8 0s g ro up in g of m or e cr iti ca l Pa ra di gm s u nt il 19 70 s Po st L og ic al E m pi ric is t a pp ro ac he s Ph ilo so ph y of Ps yc hi at ry (2 , 4 -7 ) C ar l H em pe l ( 1 95 9 ) A ss oc ia tio n f or th e I nt er na tio na l N et w or k fo r ( Lo gi ca l e m pi ric is t p hi lo so ph er A dv an ce m en t of P hi lo so ph y Ph ilo so ph y & P sy ch ia try of sc ie nc e ) a dd re ss es A PA & P sy ch ia try ( U S, 1 99 3 ) E st ab lis he d 20 02 co nf er en ce a bo ut c la ss ifi ca tio n P sy ch ia tri c C la ss ifi ca tio n Pa ra di gm at ic M od el o f Ps yc hi at ry (2 , 8 -1 4) U K : Ps yc ho an al ys is R is e of B io m ed ic al In fl u en tia l b ut M od el Le ss d om in an t Th an in U S B io m ed ic al m od el le ss d om in an t t ha n in U S B ut h as e m er ge d as m os t i nfl u en tia l p ar ad ig m V er si on s o f B io -P sy ch oSo ci al M od el c oex is t w ith m or e ps yc ho lo gi ca l & so ci al m od el s U S: Ps yc ho an al ys is A sc en da nc y of So ci al & P sy ch ol og ic al D om in an t P ar ad ig m B io m ed ic al M od el M od el s e nj oy ed sh or t be gi ns p er io d of p re -e m in en ce V ar io us v er si on s In cr ea si ng tr en d to w ar d O f B io m ed ic al M od el B io lo gi ca l r ed uc tio ni sm C oex is t i nc lu di ng p ra gm at ic w ith e m pi ric al se ar ch fo r & B io -p sy ch oso ci al a pp ro ac he s ae tio lo gy e m ph as iz ed A pp ro ac he s To V al id at io n (2 , 4 , 1 434 ) N o sy st em at ic m et ho do lo gy I n ps yc hi at ry V al id ity a ss um ed b as ed o n Th eo re tic al g ro un ds Se m in al p ap er in P sy ch om et ric s: 'C on st ru ct V al id ity in Ps yc ho lo gi ca l t es ts ' ( 1 95 5 ) 5C rit er ia e m pi ric al a pp ro ac h K en dl er a dd s v al id at or s ( R ob in s & G uz e; 1 97 0 ) ( 1 98 0s & 1 99 0s ) K en da ll on V al id ity B ig A ge nd a: R el ia bi lit y ( 19 89 ) ( a ss um pt io n th at v al id ity w ou ld in ev ita bl y fo llo w ) K en da ll & Ja bl en sk y ( 2 00 3 ) In fl u en tia l p ap er c ha lle ng in g th e va lid ity of c la ss ifi ca tio n an d de sc rib in g cl in ic al u til ity B ig A ge nd a : Va lid ity ( 'H ol y G ra il' o f ' A et io pa th og en ic v al id ity ' B ei ng se ar ch ed fo r ) D SM /IC D Ti m elin e (2 , 6 , 1 4, 2 7, 2 8, 3 544 ) D SM -I I & IC D -8 ( 19 68 ) V irt ua lly Id en tic al M ix tu re o f p sy ch oa na ly tic , B io lo gi ca l p sy ch ia try & K ra ep el in ia n co nc ep ts ; Th eo ry se pa ra te d fr om ob se rv at io n I C D -9 ( 19 77 ) N ar ra tiv eba se d; I nc lu de s g lo ss ar y R es ea rc h Fe ig hn er C rit er ia D ia gn so tic ( 1 97 2 ) C rit er ia ( 19 75 ) D SM -I II ( 19 80 ) O pe ra tio na lis ed d efi n iti on s o f c rit er ia ; B io m ed ic al m od el a do pt ed ; Ex pe rt C on se ns us D SM -I II -R ( 19 87 ) R eo rg an iz at io n of C at eg or ie s IC D -1 0 D SM -I V ( 1 99 2 ) ( 19 94 ) 'C lin ic al si gn ifi ca nc e' A dd ed ; M ul tiax ia l; O rg an ic -F un ct io na l D ic ho to m y lo st ; E m pi ric is m re pl ac es E xp er t-c on se ns us D SM -I VTR ( 2 00 0 ) C at eg or ic al W ith so m e D im en si on al a sp ec ts C rit iq ue s (6 , 33 , 3 9, 4 0, 4 460 ) A nt i-p sy ch ia try c rit iq ue U K /U S D ia gn os tic Se xu al ity & F em in is t E C A S tu di es ( p itc he d at a S tu di es C rit iq ue s o f D SM ( H ig h Pr ev al en ce ) c on ce pt ua l l ev el ) ( U nr el ia bi lit y fo un d ) C oM or bi di ty S tu dy ( H ig h C oM or bi di ty ) B ro ad C rit iq ue V al ue s So ci al o f D SM s A na ly se s C on st ru ct io ni st Le ge nd : 1 : C oo pe r, 20 08 ; 2 : F ul fo rd e t a l., 2 00 6; 3 : O ka sh a, 2 00 2; 4 : H em pe l, 19 61 ; 5 : S ad le r e t a l., 1 99 4; 6 : S ad le r, 20 05 ; 7 : S he ph er d, 1 99 5; 8 : G ha em i, 20 09 ; 9 : K ar ls so n an d K am pp in en , 1 99 5; 1 0: K ec m an ov ic a nd H ad zi Pa vl ov ic , 2 01 0; 1 1: M on cr ie ff an d C ra w fo rd , 2 00 1; 1 2: P ic ho t, 19 94 ; 1 3: P in cu s e t a l., 1 99 3; 1 4: T ay lo r a nd R ut te r, 20 08 ; 1 5: C ro nb ac h an d M ee hl , 1 95 5; 1 6: F irs t e t a l., 2 00 4; 1 7: H ym an , 2 00 2; 1 8: Ja bl en sk y, 2 01 0; 1 9: K en da ll, 1 98 9; 2 0: K en da ll, 1 98 9; 2 1: K en da ll an d Ja bl en sk y, 2 00 3; 2 2: K en dl er , 1 99 0; 2 3: K en dl er e t a l., 2 00 8; 2 4: K en dl er , 2 00 9; 2 5: K en dl er , 2 01 0; 2 6: K up fe r e t a l., 2 00 2; 2 7: R eg ie r e t a l., 2 00 5; 2 8: R eg ie r e t a l., 2 00 9; 29 : R ob in s a nd G uz e, 1 97 0; 3 0: S ch af fn er , 2 00 9; 3 1: S ch af fn er , 2 01 0; 3 2: S to ya no v, 2 00 9; 3 3: S za sz , 1 99 3; 3 4: Z ac ha r a nd K en dl er , 2 00 7; 3 5: A nd re w s e t a l., 1 99 9; 3 6: F irs t a nd P in cu s, 19 99 ; 3 7: F irs t, 20 10 ; 3 8: K en dl er e t al ., 20 10 ; 3 9: K irk a nd K ut ch in s, 19 92 ; 4 0: K ut ch in s a nd K irk , 1 99 7; 4 1: P in cu s, 20 10 ; 4 2: S he ph er d, 1 99 4; 4 3: S pi tz er , 2 00 1; 4 4: B ra ck en a nd T ho m as , 2 00 5; 4 5: B en ta ll, 1 99 2; 4 6: F ra nc es , 2 00 9; 4 7: F ou ca ul t, 19 61 /1 96 5; 48 : F ul fo rd , 1 99 4; 4 9: G er ge n, 1 99 1; 5 0: H ar re , 2 00 4; 5 1: H ar ris e t a l., 1 99 3; 5 2: Ji m in ez , 1 99 7; 5 3: K es sl er e t a l., 1 99 4; 5 4: K es sl er e t a l., 1 99 6; 5 5: L itt le w oo d, 1 99 1; 5 6: M in dh am , 1 99 2; 5 7: M is ha ra , 1 99 4; 5 8: P in cu s a nd M cQ ue en , 2 00 2; 5 9: S ch ef f, 19 66 ; 6 0: S za sz , 1 96 1. DIAL PHIL MENT NEURO SCI 2013; 6(1): 23-33 Griffi ths gests that the fi eld has increasingly emphasized the importance of reliable diagnostic practices and systematic operationalised approaches to taxonomy (Wiggins and Schwartz, 1994; Kutchins and Kirk, 1997; First and Pincus, 2004; Regier et al, 2005; Fulford et al, 2006; Kendler et al, 2008; Regier et al, 2009). Given this trend, of apparently greater interest from psychiatric professionals toward issues of classifi cation, it would be expected this would be refl ected by an increased proportion of the mainstream psychiatric literature devoted to it (Kendler et al, 2008). Further analysis of historical accounts reveals that, with the biomedical paradigm gradually achieving more dominance, both in US and UK, empirical approaches to classifi cation became more prominent as more theoretically-based approaches diminished in importance (Robins and Guze, 1970; Kendler, 1990;Hyman, 2002; Kendall, 2002; Kupfer et al, 2002). It would be expected that, coupled with the explicit taxonomical agenda of enhancing reliability, writing about classifi cation would show a trend of focusing increasingly on empirical approaches. It has been acknowledged that the pursuit of validity in psychiatric classifi cation, which has adopted an essentially empirical methodology since the 1970s, has remained elusive and remains the explicit agenda priority for future classifi ers (Kupfer et al, 2002; Kendall and Jablensky, 2003; Regier et al, 2009; Schaffner, 2010). Given that validation involves a host of conceptual issues in addition to empirical contributions it might be expected that literature, which addresses classifi cation issues, would have increasingly shown a trend toward a more conceptual orientation throughout the last fi fty years. The survey aimed to examine these hypothesized trends in interest and make some speculative inferences based on the data obtained. METHODOLOGY Identifi cation and categorisation of journal articles: The survey utilizes a bibliometric methodology (David and Ritchie, 1978). A content analysis (Krippendorff, 2004) of the titles of all the main journal articles from the fl agship psychiatric journals from the US and UK , the AJP and BJP, 28 over a fi fty year period (1960-2010) was carried out. All journal articles except "brief reports" or "case reports" were included. Those papers which were explicitly related to classifi cation issues were identifi ed. A "classifi cation" article was identifi ed if it explicitly included in its title the word "classifi cation" or related pre-specifi ed term within a sentence-context that suggested such a focus. As an additional exploratory analysis the study endeavoured to make the following further distinctions about these identifi ed papers: Whether there was a focus on empirical or conceptual (or both) aspects of classifi cation; Whether the papers address classifi cation issues more generally/as-a-whole or whether they had a more narrow specifi c focus, e.g. diagnosisspecifi c. In order to allow direct comparisons of the different proportions of the different types of classifi cation articles between the two journals and between decades a correction calculation was carried out. This was required as there was little uniformity in the average number of articles published each year for the journals. The fi gures included in the results section involve data corrected using this calculation. Defi nitions of terms It has been shown that high-order abstract constructs such as "classifi cation", "conceptual", or "empirical" are easier to use than they are to defi ne. Many, if not all, of the constructs pervasively used within the fi eld of psychiatry are perhaps best considered "family resemblance" terms (Wittgenstein, 1953). Although terms will necessarily evade complete and un-contentious defi nition, attempts will be made to illuminate the meanings of the relevant terms as they are used in the context of this paper. This diffi culty of methodology, in fact, directs attention to one of the main points being addressed by this paper, namely, that conceptual considerations appear and need to be exposed and debated at every level within the diverse fi eld of psychiatric practice and research. Data Analysis Overall number counts of journal articles of interest and relevant proportion calculations were obtained. Simple graphic analysis was used to yield some visible trends in article publicawww.crossingdialogues.com/journal.htm 29 tion. Histograms were used to display the numbers of articles per decade. Line plots were used to display the trends by year. The visual impressions of the distribution of data were provided by these formats. Basic descriptive statistical analyses were used to examine the hypothesized publication trends described above. The primary outcome examined was the proportion of articles focusing on classifi cation each year for both journals together and for conceptual and empirical articles combined. Secondary analyses were also conducted for: i) the two journals separately, ii) conceptual and empirical classifi cation articles separately, and iii) general and specifi c classifi cation articles separately. RESULTS Of the 23006 articles surveyed in fi fty years of the two journals 4.7% explicitly focused on classifi cation issues. Only a small percentage of articles were solely focused on classifi cation issues at a conceptual level (0.5% for BJP and 0.6% for AJP). In both journals the proportion of "specifi c" outweighed the "general" classifi cation articles (BJP4:1 ; AJP3:1). There was evidence that the proportion of journal articles relating to classifi cation, for both journals, have increased over time. The increase over time was relatively small (an increase in proportion of articles of approximately 0.5% per decade). This was similar for both journals when examined separately. Equally, there was evidence that the proportion of journal articles relating to empirical classifi cation have increased over time. In contrast, the proportion of journal articles relating to conceptual classifi cation have decreased over time (see Figure I). Similarly, the proportion of journal articles relating to general classifi cation have decreased, whereas those relating to more specifi c aspects of classifi cation have increased over time (see Figure II). On analysing the line plots generated by the data it was found that some of the peaks in interest (i.e., the years with the greatest numbers of published articles) appeared to coincide with known, signifi cant to classifi cation, historical events. This was especially true of the AJP, e.g. the decade considerably more interested in conceptual aspects was the AJP in the1960s (which would coincide with the move to usurp psychoanalysis as dominant paradigm in US and need to address an essentially conceptual anti-psychiatry critique); Peak years of AJP interest in classifi cation: 1969 (soon after publication of UK/US diagnostic studies and ICD-8/DSM-II published in 1968); 1980 (DSM-III published); 1994 (DSMIV published). Although there were differences in the levels of interest by year and by decade in the BJP the peaks and trends were not as marked as they were for the AJP. Figure I shows the numbers of articles focusing on either conceptual or empirical aspects of classifi cation in both journals by decade. It can be observed that interest in empirical aspects is generally greater in the last three decades with Figure I DIAL PHIL MENT NEURO SCI 2013; 6(1): 23-33 Griffi ths peaks in the 1980s and 1990s. Whilst lower interest in conceptual aspects is consistent across journals there is more variability in the AJP than the BJP. The AJP published signifi cantly more conceptually-oriented classifi cation papers in the fi rst three decades than the last two, with by far the fewest in 2000s. In contrast the trend of publishing conceptual papers in the BJP remained fairly stable across the fi fty years. Figure II shows the comparison of general to specifi c classifi cation papers of the two journals by decade. It can be seen that there were twice as many published general classifi cation articles in the 1970s than any other decade. The 1980s and 1990s had similar rates of interest with the 1960s and 2000s having least publications. The last 3 decades studied had considerably more specifi c classifi cation articles published. The 1960s was the decade which published least specifi c classifi cation articles. DISCUSSION This survey, in spite of its limitations to draw clear conclusions, does lend some support to the idea that there has been little interest in the conceptual issues involved in psychiatric classifi cation. There is a slight trend towards increased Figure II interest in classifi cation with empirical aspects being increasingly emphasized throughout the fi rst four decades with a slight drop in the last decade. Interest in conceptual aspects has generally decreased by decade in both countries. The survey seemed to mirror, to some extent, the fi ndings of Kecmanovic and Hadzi-Pavlovic ( 2010 ) which found that the AJP more than the BJP was infl uenced by prevailing paradigmatic trends identifi ed by historians. Study Limitations. The papers were coded by only one person so reliability cannot be assured. Also, inevitable defi nitional ambiguities surrounding the terms of interest for the study should lead to cautious interpretation of the survey fi ndings. Conclusion. A group of eminent nosologists, researchers and philosophers wrote a recent editorial in the AJP presenting a range of powerful arguments suggesting that DSM-V should include a conceptual issues work group (Kendler et al, 2008, p.3). No such work group was established! Future revisions should surely create and make use of such a group. It might not be an explicit preference of many psychiatrists to grapple with the conceptual complexity and dilemmas faced by the fi eld but 30 Comparison of Specifi c & General Classifi cation Papers No. of Articles Am J Psychiatry Specifi c classifi cation (Total) Am J Psychiatry General classifi cation (Total) Brit J Psychiatry Specifi c classifi cation (Total) Brit J Psychiatry General classifi cation (Total) 1960s 1970s 1980s 1990s 2000s 140 120 100 80 60 40 20 0 www.crossingdialogues.com/journal.htm the position articulated by one of psychiatry's pioneering founders Karl Jaspers remains highly relevant, "many a psychiatrist has said that he did not want to burden himself with a philosophy...but the exclusion of philosophy would... be disastrous for psychiatry" (Jaspers, 1959/1963, p. 769). Is it possible that some combination of the following phenomena may be present within the psychiatric fi eld: conceptual-complacency, conceptual-blindness or conceptual-disinterest? 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