George & Klijn's paper (2013) will undoubtedly be met with controversy from those who believe there really is a definable mental ‘illness’ called ‘schizophrenia’ and that the diagnosis leads to effective treatments. Some will see the objection to the schizophrenia label as being ‘anti-psychiatry’ and a step too far. Others, however, will feel this paper does not go far enough, merely suggesting the replacement of one term with little reliability and validity with another.
There is no doubt that for many, the diagnosis of schizophrenia can be as debilitating as the associated symptoms. The internalization of stigmatizing public and professional perceptions of schizophrenia as an irreversible brain disease associated with violence and unpredictability can impact on identity, self-esteem, self-efficacy, hope and social functioning (Livingston & Boyd, Reference Livingston and Boyd2010). Similarly, it is clear that internalized stigma can deter help-seeking and contribute to social exclusion. The impact of identifying with the diagnosis can in itself have a detrimental impact on recovery (Link et al. Reference Link, Struening, Neese-Todd, Asmussen and Phelan2001). Although it is important to recognize that for some people the diagnosis confers benefits including naming the problem and providing a means of access to support (Pitt et al. Reference Pitt, Kilbride, Welford, Nothard and Morrison2009), the implied permanence and severity of the supposed condition can be debilitating. A key question in all this is whether changing the name would be enough in itself to change public attitudes and reduce self-stigma, while hopefully maintaining any potential benefits, or would such stigma become re-aligned with the new diagnostic term.
Some organizations have grown tired of waiting for official abandonment of the term. In both the UK and New Zealand family organizations that used to call themselves the Schizophrenia Fellowship have changed to Rethink and Supporting Families, respectively. In 2012 the membership of the International Society for the Psychological Treatments of Schizophrenia voted overwhelmingly to change its name to the International Society for Psychological and Social Approaches to Psychosis. In Japan, the name change was linked to an educational campaign which is likely to have contributed to the change in attitudes.
Beyond the many studies finding that use of the label increases negative attitudes (Read et al. Reference Read, Haslam, Sayce and Davies2006) research repeatedly demonstrates that beliefs about the causes of schizophrenia play a significant role in stigmatizing attitudes. The most recent review found that in 28 of 31 studies bio-genetic causal beliefs are related to negative attitudes and that in 24 of 26 studies psycho-social causal beliefs were related to positive attitudes (Read et al. Reference Read, Haslam, Magliano, Read and Dillonin press).
There is a significant overlap in symptoms (and it could be argued, causes) between PTSD and schizophrenia (Morrison et al. Reference Morrison, Frame and Larkin2003). At times of diagnostic uncertainty, and despite the stigma linked to PTSD, many of those with psychosis would prefer this diagnosis or one of ‘complex trauma’ as an acceptable explanation and description of their experiences. Interestingly, Moskowitz & Heim (Reference Moskowitz and Heim2012) argue that when Bleuler suggested ‘Dementia praecox’ be renamed to ‘Schizophrenia’, he was not only challenging the assumed chronic deteriorating nature of the condition but, influenced by Janet, was acknowledging the dissociative aspect of psychosis, that presently we would consider to be trauma induced. This psychological element of schizophrenia was unfortunately neglected until recent times. The portrayal of schizophrenia as purely a bio-genetic condition has contributed to the high levels of associated stigma (Read & Harre, Reference Read and Harre2001; Angermeyer & Matschinger, Reference Angermeyer and Matschinger2003).
The renaming of schizophrenia to the equivalent of a post-traumatic stress reaction would, of course, be unacceptable to those who do not associate their psychosis with life experiences. However, evidence suggests that the majority of people who receive the diagnosis (Dudley et al. Reference Dudley, Siitarinen, James and Dodgson2009), like family members and the general public (Read et al. Reference Read, Haslam, Sayce and Davies2006), view the causes of psychosis, as being predominantly of psychosocial origin. The heterogeneity within the population who receive a diagnosis of schizophrenia would suggest that there will be multiple aetiological pathways that incorporate many such factors, and preliminary evidence suggests that many service users find labels that allow for this (such as traumatic psychosis and drug-induced psychosis) may be more acceptable (Kingdon et al. Reference Kingdon, Gibson, Kinoshita, Turkington, Rathod and Morrison2008). This highlights another strong argument for abandoning the term schizophrenia: the lack of construct validity. At present there are no specific features of schizophrenia (symptoms, course, response to treatment and aetiology) that distinguish it from other disorders (Bentall, Reference Bentall2003), which means that the diagnosis has limited predictive power and utility. If as George & Klijn (Reference George and Klijn2013) suggest, schizophrenia is relabelled as a syndrome this would at least openly acknowledge that psychiatry does not see it as a single entity.
The word ‘schizophrenia’ appears to do more harm than good, more frequently communicating prejudice and misinformation than fact and hope. It is indisputable that the stigma surrounding the term schizophrenia can in itself lead to misery for many with the diagnosis. Despite this, the diagnosis of schizophrenia is unlikely to disappear for a number of years. The APA has continued to endorse schizophrenia as a diagnosis in the revised and updated diagnostic manual DSM-5, due to be published later in 2013.
Some would question the merits of classifying emotions, behaviours and experiences into diagnostic groups at all, although classification and diagnoses are central to traditional medicine. Whether a system that was developed for studying diseases and illnesses has utility beyond primarily physical conditions is questionable. Despite there often being as many, if not more, differences than similarities in those with the same diagnosis, treatment guidelines, service configuration and research tend to be diagnosis specific and individual differences can be overlooked. Some argue that DSM and ICD have led to the medicalization of mental distress. The application of medical terminology such as ‘symptom’, ‘mental illness’ and ‘disease’ to human experience, infers pathology with an identified fundamental biological aetiology. A common complaint of service users is that they are treated as merely a set of symptoms and are not seen as person with a life beyond mental health services. The use of terms such as ‘schizophrenic’ reflect this practice of identifying individuals by their diagnosis. Therefore, any label that removes some of these disadvantages would be a welcome change.
Declaration of Interest
None.
