Renaming schizophrenia

Abstract

The movement towards renaming of schizophrenia in Japan started in 1993 upon receipt of a letter by The National Federation of Families with Mentally Ill in Japan addressed to the board of Japanese Society of Psychiatry of Neurology (JSPN), requesting to rename schizophrenia as the then-official term for the condition, Seishin-Bunretsu-Byo, or ‘mind-splitting disease’, was humiliating. A committee was established within JSPN to address the issue, public comments were collected, a new name ‘Togo-Shitcho-Sho’ (‘disintegration disorder’) was approved in 2002, and in 2005, the new name was adopted in the Revised Mental Health and Welfare Act. This paper describes the process of renaming, and also the current situation in Korea, Taiwan, China, Hong Kong and Malaysia, where Chinese characters are used. Also, it presents alternative names for schizophrenia that have been suggested in the process of two research projects conducted by the authors and also additional candidates suggested by others.

Introduction

The prevalence of schizophrenia is estimated to be approximately 1% and around the world 24 million people are said to suffer from the illness. The condition initially coined as Dementia Praecox by Kraepelin was renamed as Schizoprenie, or schizophrenia, by Bleurer, and the term has been used for over a century now. However, this term schizophrenia has been revisited recently for a possibility of renaming.

The renaming movement in Japan

In Japan, as a corresponding translation for schizophrenia, Seishin-Bunretsu-Byo (‘mind-splitting disease’) was approved in 1937 by a committee for psychiatric terminology within Japanese Society for Psychiatry and Neurology (JSPN), and it has been used since then. However, The National Federation of Families with Mentally Ill in Japan (NFFMIJ) wrote a letter in 1993 to the President of JSPN, requesting to rename the condition on the ground that ‘the term Seishin-Bunretsu-Byo is humiliating’. In response to this letter, JSPN started to organise a subcommittee and a special committee designated move forward with renaming (Table 1) (Sato, 2006, 2008).

Table 1. Actions towards renaming the disease

This committee established criteria to use when considering the new name: the new name should (1) not result any social disadvantage to patients, (2) reflect the concept of schizophrenia, (3) not intend to stand for a disease entity but syndrome, (4) be easy to understand and (5) be distinguished from other disorders. This committee met frequently, and they narrowed down the possibilities to three candidates: Togo-Shitcho-Sho (‘disintegration disorder’), Sukizofurenia (‘schizophrenia’ spelled out according to the Japanese writing system) and Bleurer's disease. JSPN members were asked to comment on those three candidates, and at the JSPN General Assembly, Togo-Shitcho-Sho received the final approval. The new term was publicly introduced at the XIIth International Congress of World Psychiatric Association, and a month later, the Japanese government officially endorsed this as well.

However, it took 3 more years to have the Japanese Mental Health and Welfare Law reflect the change. To change the disorder name already used in the laws, it was necessary to demonstrate how much awareness the proposed term has gained and the effects that the new term is expected to have on various departments of the Japanese government. To provide evidence, two research projects were conducted by the Health Labour Sciences Research Grants in Japan (Sato, 2004; Ono, 2004).

It has come to be widely known that Japan re-named schizophrenia, but less known is the fact that schizophrenia was re-conceptualised. Sato (Sato, 2008) reports that, along with the renaming from ‘mind-split disease’ to ‘disintegration disorder’, the following changes were made:

• • Schizophrenia is a syndrome, not a disease (i.e., discontinuation from the conceptualisation of dementia praecox).

• • It is delineated by specific clinical symptoms, rather than vulnerability of brain.

• • The illness and personality are assessed in separate dimensions, rather than in combination.

• • Its aetiology is dysregulation of neurotransmitter system and heterogeneity in heredity is observed, rather than simply ‘unknown’.

• • The overall severity of the condition is milder than before.

• • Its course and outcomes is ‘recovery in more than a half’ instead of ‘progressive and poor’.

• • Informed consent and psychoeducation for the patients are ‘easy’, not ‘difficult’.

• • Recommended treatment is now a combination of medication and psychosocial therapy, rather than medication alone.

The situation in Asian, Europe countries and the USA

Movement of renaming is observed in other Asian countries where Chinese characters are also in use. The Korean term for schizophrenia had been ‘Jeongshin-bunyeol-byung’ (‘mind-split disorder’), which was changed in 2012 to ‘Johyun-byung’ (‘attunement disorder’) by Korea Psychiatric Association (Lee and Kwon, 2011; Lee et al., 2013). Behind this change was discrimination against the affected patients and caregivers and also mental health professionals due to the old term. In addition, the old term was often confused with dissociative identity disorder. Commenting on the new term, Lee et al. (2013) report that ‘Johyeon literally means “to tune a stringed musical instrument”. In the context of schizophrenia, attunement is a metaphor for tuning the strings of the mind.’

In Taiwan, Taiwanese Society of Psychiatry decided to rename the term from ‘Jing Shen Fen Lie Zheng’ (‘mind-split disease’) to ‘Si Jue Shi Tiao Zheng’ (‘dysfunction of thought and perception’).

Hong Kong seems to be entertaining the possibility of renaming; neither China nor Singapore seems to (Sartorius et al., 2014).

There are researchers proposing to consider renaming schizophrenia in Europe and America as well, which seems to suggest an increasing interest in renaming. This may be partially motivated by publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by the American Psychiatric Association and upcoming publication of the International Classification of Diseases and Related Health Problems, 11th Revision (ICD-11) by the World Health Organization. Of note, the ICD-11 is expected to be approved at the World Health Assembly in May 2019, but schizophrenia is not planned to be renamed.

In the Netherland, an organisation called Anoiksis (a completely consumer-run association of people who have chronic psychoses or schizophrenia) is actively promoting renaming of schizophrenia. Information regarding how users are approaching renaming is scant, but it is noteworthy how similar the movement in the Netherland is to the process in which renaming of schizophrenia in Japan started with NFFMIJ, the organisation run by users (George and Klijn, 2013a, 2013b).

Alternative names for schizophrenia that have been suggested in the process of two research projects conducted by the authors and also additional candidates suggested by others

The authors have conducted two surveys regarding renaming of schizophrenia (Maruta and Iimori, 2008; Maruta et al., 2014; Maruta and Matsumoto, 2016). These research projects and proposed candidate terms suggested by others are summarised in Table 2.

Table 2. Alternative names for schizophrenia that have been suggested in the process of two research projects conducted by the authors and additional candidates suggested by others

Conclusion

The movement of renaming schizophrenia originally started in Japan and other Asian countries has attracted international interest. Schizophrenia is among key disorders of all mental disorders, which may explain the high interest.

Some people are for renaming and others are against it. The significance of renaming is to reduce the stigma associated with the term schizophrenia and ultimately contribute to removing obstacles that exist in mental health care. Within Chinese character-using countries including Japan, it is quite possible that the initial translation (i.e., a translation that stands for ‘mind-split disease’) was inappropriate to begin with. Back then when that term was proposed, the concept of informed consent did not exist, and the viewpoint of how the disorder name might affect the patients, families and society was lacking while the translation was done, and scientific knowledge regarding the pathology was extremely limited. Today the situation is different. While the aetiology of schizophrenia is yet to be discovered, the environment surrounding schizophrenia has changed to a large extent.

When choosing a new term, it is important to involve the patients and families who suffer the consequences of the illness in addition to the mental health professionals, inviting them to state their opinions. They also agree that, in addition to the new term, new conceptualisation of the illness must follow, according to our research. In order to reduce stigma, education about the illness to the public seems critical.

It may take time, but it seems important to promote psychiatric care that encourages interest in renaming, aims to reduce stigma against schizophrenia and ultimately facilitates hope for the patients and families.