Hostname: page-component-6b989bf9dc-wj8jn Total loading time: 0 Render date: 2024-04-13T09:02:00.024Z Has data issue: false hasContentIssue false

Would a rose, by any other name, smell sweeter?

Published online by Cambridge University Press:  17 June 2013

RICHARD P. BENTALL*
Affiliation:
Institute of Psychology, Health & Society, Liverpool University, UK
Rights & Permissions [Opens in a new window]

Abstract

Type
Forum
Copyright
Copyright © Cambridge University Press 2013 

Methods of psychiatric classification have numerous uses, ranging from the clinical (communication between clinicians, the facilitation of decisions about treatment), to the scientific (selecting participants for research into the aetiology and treatment of mental illness), through to the social and political (keeping statistics about mental health, developing mental health policy). Diagnoses also have unintended consequences, as emphasized by George & Klijn (Reference George and Klijn2013), who argue that the term ‘schizophrenia’ increases the stigma experienced by psychiatric patients, and that it should therefore be replaced by something else. They cite the experience of Japan, where replacing the term with Togo-Shitcho Sho (integration dysregulation syndrome) is claimed to have ameliorated the stigma experienced by patients. While I applaud the overall goal of reducing stigma, and sympathize with authors' suggestion, I think that simple rebranding is unlikely to be enough to achieve what they desire.

The problems of schizophrenia

Schizophrenia has been a contested label for many years (Sarbin & Mancuso, Reference Sarbin and Mancuso1980; Bentall et al. Reference Bentall, Jackson and Pilgrim1988) not only because it is associated with stigma, but also because it fails to achieve any of the purposes for which it was originally designed. Even in the world of operationalized diagnostic criteria, different definitions of schizophrenia sometimes define different people as schizophrenic (van Os et al. Reference van Os, Gilvarry, Bale, van Horn, Tattan, White and Murray1999). In carefully conducted studies in which patients are followed up over time, patients sometimes move from one diagnosis to another within the psychosis spectrum (Bromet et al. Reference Bromet, Kotov, Fochtmann, Carlson, Tanenberg-Karant, Ruggero and Chang2011) and diagnostic shifts, for example between schizophrenia and bipolar disorder, are probably much more common in the rough and tumble of routine psychiatric care. Statistical analyses of symptoms fail to provide any support for the kind of categorical diagnoses contained within the DSM or ICD systems (Kotov et al. Reference Kotov, Chang, Fochtmann, Mojtabai, Carlson, Sedler and Bromet2011). Instead, the psychotic disorders seem best described in terms of five relatively independent dimensions of positive symptoms, negative symptoms, cognitive disorganization, depression and mania (Demjaha et al. Reference Demjaha, Morgan, Morgan, Landau, Dean, Reichenberg, Fearon, Hutchinson, Jones, Murray and Dazzan2009), although there may also be a superordinate general psychosis dimension (Reininghaus et al. Reference Reininghaus, Priebe and Bentall2012), which is also suggested by genetic research (Craddock & Owen, Reference Craddock and Owen2005). Importantly, there is considerable evidence that at least some of these dimensions lie on continua with normal functioning (Linscott & van Os, Reference Linscott and van Os2010). Not surprisingly, given these findings, there is very little evidence that categorical diagnoses, at least in the psychotic domain, predict treatment response. Patients diagnosed as suffering from bipolar disorder, like those diagnosed with schizophrenia, are now commonly treated with antipsychotic drugs, leading to suspicions that patients with the two diagnoses suffer from a common dopaminergic disorder (Tamminga & Davis, Reference Tamminga and Davis2007). The only study which, to this author's knowledge, has randomly assigned patients in the psychosis spectrum to an antipsychotic (pimozide) and/or a mood stabilizer (lithium) found almost no evidence that diagnosis was a useful predictor of treatment response (Johnstone et al. Reference Johnstone, Crow, Frith and Owens1988).

Rebranding schizophrenia solves none of these problems. By replacing one ill-fitting label with another, we do nothing to advance psychiatric research or to develop better treatment plans for our patients. Moreover, some of the proposed rebrandings are potentially misleading – for example ‘salience syndrome’ (van Os, Reference van Os2009) implies the acceptance of one particular biological model of positive symptoms (Kapur et al. Reference Kapur, Mizrahi and Li2005), ignores other kinds of models (what about ‘self-monitoring deficiency syndrome’?) and cannot apply to dimensions other than the positive. Nor is it obvious how, in the long-term, this kind of rebranding will ameliorate the unintended consequence of the schizophrenia label that concerns George & Klijn (Reference George and Klijn2013).

Of course, it is possible that the label is now so toxic that changing the name may well have a temporary effect, but unless the real causes of stigma are addressed, in a matter of only a few years the new term is likely to acquire its own toxic qualities, every bit as troublesome as those of its predecessor.

It is not hard to locate some of these causes. Without a doubt, one is the media's treatment of schizophrenia, which consistently over-emphasizes the risk of dangerous behaviour by patients (Philo et al. Reference Philo, Secker, Platt, Henderson, McLaughlin and Burnside1994; Coverdale et al. Reference Coverdale, Nairn and Claasen2002; Owen, Reference Owen2012), conveying the impression that people with psychosis are responsible for an epidemic of interpersonal violence. The reality is, of course, quite different. Whereas there is an increased risk of violence associated with psychosis, most of this is attributable to co-morbid substance abuse (Fazel et al. Reference Fazel, Gulati, Linsell, Geddes and Grann2009) and most psychiatric patients pose absolutely no risk to their neighbours.

A second, less obvious source of the toxicity of the schizophrenia label is the hopelessness that surrounds it. For example, consistent with Kraepelin's original conception of dementia praecox, for many clinicians, patients and the general public, the term implies a life doomed to be limited by mental illness until death. Again, the reality is different, with many patients making a full recovery, and others being able to pursue a fulfilling life despite persisting symptoms and disability (Ciompi, Reference Ciompi1984; Harding, et al. Reference Harding, Brooks, Ashikage and Strauss1987). It is findings such as these that have led to a radical reappraisal of the concept of recovery from severe mental illness (Anthony, Reference Anthony1993).

Finally, the background scientific assumptions that surround the label schizophrenia make a major contribution to the stigma associated with it. Many of those who defend the term support a narrow biomedical conception of psychosis as a largely genetically determined neurological condition, while objecting to any possibility that there may be important social and environmental determinants. For example, in an editorial in the British Medical Journal supporting the retention of the schizophrenia label, Lieberman & First (Reference Lieberman and First2007) asserted that,

Although a diagnosis of schizophrenia depends on the presence of a pattern of symptoms … evidence shows that these are manifestations of brain pathology. Schizophrenia is not caused by disturbed psychological development or bad parenting.

Consistent with this viewpoint, mental health literacy campaigns have typically promoted the idea that schizophrenia is ‘an illness like any other illness’ (Read et al. Reference Read, Haslam, Sayce and Davies2006).

The irony is not only that a narrow biomedical conception of schizophrenia (whatever the term refers to) is no longer scientifically defendable (contrary to Lieberman & First, there is compelling evidence that adverse early childhood experiences play an important causal role in psychosis; Varese et al. Reference Varese, Smeets, Drukker, Lieverse, Lataster, Viechtbauer, Read, van Os and Bentall2012) but also that genetic-neurological accounts of psychosis actually increase the stigma experienced by psychiatric patients (Read et al. Reference Read, Haslam, Sayce and Davies2006; Angermeyer, et al. Reference Angermeyer, Holzinger, Carta and Schomerus2011). The general public, it seems, finds accounts of mental illness that emphasize environmental stressors, not only more believable, but more sympathy-evoking than accounts that emphasize genetic and neurological factors. From a common sense perspective this should not be surprising. (Who would the reader prefer to live next-door to – someone who is behaving erratically because of some kind of life trauma, or someone whose unpredictable behaviour is the consequence of some kind of endogenous genetic defect in the central nervous system?)

Conclusion

When, at the beginning of my career, I first argued that the concept of schizophrenia should be abandoned (Bentall et al. Reference Bentall, Jackson and Pilgrim1988) it was widely regarded as a marginal, perhaps preposterous position. From a purely personal perspective, it is satisfying that what was once marginal is now in danger of becoming mainstream. The problem has become not whether to replace schizophrenia, but what to replace it with. Simple relabelling will do nothing to address the many scientific and clinical limitations of the categorical approach to diagnosis that I have briefly summarized. Nor is it likely to address the problem of stigma, which arises out of background assumptions about the nature of severe mental illness. To persuade the general public to be more accepting of people with mental illness, we must persuade them that psychosis arises, in part, understandably from adverse life experiences (while of course acknowledging that genetic factors must play some role), that it does not necessarily lead to violence, and that recovery is possible. Fortunately, there is a now a considerable volume of research that supports this position.

Declaration of Interest

None.

References

Angermeyer, MC, Holzinger, A, Carta, MG, Schomerus, G (2011). Biogenetic explanations and public acceptance of mental illness: systematic review of population studies. British Journal of Psychiatry 199, 367372.CrossRefGoogle ScholarPubMed
Anthony, W (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal 16, 1123.CrossRefGoogle Scholar
Bentall, RP, Jackson, HF, Pilgrim, D (1988). Abandoning the concept of schizophrenia: Some implications of validity arguments for psychological research into psychotic phenomena. British Journal of Clinical Psychology 27, 303324.CrossRefGoogle ScholarPubMed
Bromet, EJ, Kotov, R, Fochtmann, LJ, Carlson, GA, Tanenberg-Karant, M, Ruggero, C, Chang, SW (2011). Diagnostic shifts during the decade following first admission for psychosis. American Journal of Psychiatry 168, 11861194.CrossRefGoogle ScholarPubMed
Ciompi, L (1984). Is there really a schizophrenia?: the longterm course of psychotic phenomena. British Journal of Psychiatry 145, 636640.CrossRefGoogle ScholarPubMed
Coverdale, J, Nairn, R, Claasen, D (2002). Depiction of mental illness in print media: a prospective national sample. Australian and New Zealand Journal of Psychiatry 36, 697700.CrossRefGoogle ScholarPubMed
Craddock, N, Owen, M (2005). The beginning of the end for the Kraepelinian dichotomy. British Journal of Psychiatry 186, 364366.CrossRefGoogle ScholarPubMed
Demjaha, A, Morgan, K, Morgan, C, Landau, S, Dean, K, Reichenberg, A, Fearon, P, Hutchinson, G, Jones, PB, Murray, RM, Dazzan, P (2009). Combining dimensional and categorical representation of psychosis: the way forward for DSM-V and ICD-11? Psychological Medicine 39, 19431955.CrossRefGoogle ScholarPubMed
Fazel, S, Gulati, G, Linsell, L, Geddes, JR, Grann, M (2009). Schizophrenia and violence: Systematic review and meta-analysis. PLoS Medicine 6, e1000120.CrossRefGoogle ScholarPubMed
George, B, Klijn, A (2013). A modern name for schizophrenia (PSS) would diminish self-stigma. Psychological Medicine. doi: 10.1017/S0033291713000895.CrossRefGoogle ScholarPubMed
Harding, CM, Brooks, GW, Ashikage, T, Strauss, JS (1987). The Vermont longitudinal study of persons with severe mental illness: II. Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry 144, 727735.Google ScholarPubMed
Johnstone, E, Crow, T, Frith, CD, Owens, D (1988). The Northwick Park 'functional psychosis' study: diagnosis and treatment response. Lancet ii, 119125.CrossRefGoogle Scholar
Kapur, S, Mizrahi, R, Li, M (2005). From dopamine to salience to psychosis – linking biology, pharmacology and phenomenology of psychosis. Schizophrenia Research 79, 5968.CrossRefGoogle ScholarPubMed
Kotov, R, Chang, SW, Fochtmann, LJ, Mojtabai, R, Carlson, GA, Sedler, MJ, Bromet, EJ (2011). Schizophrenia in the internalizing-externalizing framework: a third dimension? Schizophrenia Bulletin 37, 11681178.CrossRefGoogle ScholarPubMed
Lieberman, JA, First, MB (2007). Renaming schizophrenia: diagnosis and treatment are more important than semantics. British Medical Journal 334, 108.CrossRefGoogle Scholar
Linscott, RJ, van Os, J (2010). Systematic reviews of categorical versus continuum models in psychosis: evidence for discontinuous subpopulations underlying a psychometric continuum. Implications for DSM-V, DSM-VI, and DSM-VII. Annual Review of Clinical Psychology 6, 391419.CrossRefGoogle ScholarPubMed
Owen, PR (2012). Portrayals of schizophrenia by entertainment media: a content analysis of contemporary movies. Psychiatric Services 63, 655659.CrossRefGoogle Scholar
Philo, G, Secker, J, Platt, S, Henderson, L, McLaughlin, G, Burnside, J (1994). The impact of the mass media on public images of mental illness: media content and audience belief. Health Education Journal 53, 271282.CrossRefGoogle Scholar
Read, J, Haslam, N, Sayce, L, Davies, E (2006). Prejudice and schizophrenia: a review of the 'mental illness is an illness like any other' approach. Acta Psychiatrica Scandinavica 114, 303318.CrossRefGoogle ScholarPubMed
Reininghaus, U, Priebe, S, Bentall, RP (2012). Testing the psychopathology of psychosis: Evidence for a general psychosis dimension. Schizophrenia Bulletin. Published online: 18 January 2012. doi: 10.1093/schbul/sbr182.Google ScholarPubMed
Sarbin, TR, Mancuso, JC (1980). Schizophrenia: Diagnosis or Moral Verdict? Oxford: Pergamon.Google Scholar
Tamminga, CA, Davis, JM (2007). The neuropharmacology of psychosis. Schizophrenia Bulletin 33, 937946.CrossRefGoogle ScholarPubMed
van Os, J (2009). ‘Salience syndrome’ replaces ‘schizophrenia’ in DSM-V and ICD-11: Psychiatry's evidence-based entry into the 21st century? Acta Psychiatrica Scandinavica 120, 363372.CrossRefGoogle Scholar
van Os, J, Gilvarry, C, Bale, R, van Horn, E, Tattan, T, White, I, Murray, R (1999). A comparison of the utility of dimensional and categorical representations of psychosis. Psychological Medicine 29, 595606.CrossRefGoogle ScholarPubMed
Varese, F, Smeets, F, Drukker, M, Lieverse, R, Lataster, T, Viechtbauer, W, Read, J, van Os, J, Bentall, RP (2012). Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective and cross-sectional cohort studies. Schizophrenia Bulletin 38, 661671.CrossRefGoogle ScholarPubMed