BMJ  2007;334:108 (20 January), doi:10.1136/bmj.39057.662373.80

Editorials

Renaming schizophrenia

Diagnosis and treatment are more important than semantics

Recent reports in the media have called for schizophrenia to be "abolished as a concept" because it is scientifically meaningless.¹ This is not the first time that the validity of this diagnostic entity has been challenged, and it will not be the last until the cause of the disorder and its precise pathophysiology are known.

The current system of psychiatric diagnosis cannot describe definitive disease entities because of our inability to demonstrate "natural" boundaries between disorders. However, as Kendell and Jablensky point out, "thoughtful clinicians have long been aware that diagnostic categories are simply concepts, justified only by whether they provide a useful framework for organising and explaining the complexity of clinical experience in order to derive inferences about outcome and to guide decisions about treatment."² In this context, the charge that schizophrenia does not define a specific illness is clearly unwarranted. Although the validity of the diagnosis remains to be established, its diagnostic reliability and usefulness are indisputable.

For more than 100 years schizophrenia has been an integral part of our nosology and has facilitated research and treatment of people affected by this disease.^{3 4} People qualify for the diagnosis if their clinical signs and symptoms conform to the operational diagnostic criteria that define schizophrenia. Many studies have shown that these diagnostic criteria can be applied reliably and accurately by trained mental health professionals.^{5 6} Although a diagnosis of schizophrenia depends on the presence of a pattern of symptoms (such as delusions, hallucinations, disorganised speech, disorganised or catatonic behaviour, and negative symptoms such as lack of motivation), evidence shows that these are manifestations of brain pathology.⁷ Schizophrenia is not caused by disturbed psychological development or bad parenting. Compared with normal controls, people with schizophrenia have abnormalities in brain structure and function seen on neuroimaging and electrophysiological tests. In addition, the evidence that vulnerability to schizophrenia is at least partly genetic is indisputable.⁸

Once a diagnosis of schizophrenia is made, the treating clinician has a wide array of treatment options available, which have been tested empirically on similar groups of people. Furthermore, the doctor will also have access to the huge body of empirical data that characterises this condition including its course, treatment response, outcome, and family history. This is important because evidence shows that early intervention may improve outcome.⁹ The diagnosis also helps when explaining to the patient and their family the nature of the problem, the range of treatments and outcomes, and the assistance available from support groups.

Of course, diagnostic labels have potential disadvantages. If a diagnosis of schizophrenia is mistakenly applied, the patient will receive the wrong treatment and potentially have the stigma of having a mental illness. For example, if a patient with a toxic (such as phencyclidine induced) psychosis is misdiagnosed with schizophrenia, he or she may be given a long and unnecessary course of antipsychotic drugs. To avoid this situation, psychiatric diagnoses have built-in safeguards in the form of exclusion criteria that prevent a diagnosis from being made if certain conditions are present (for example, a diagnosis of schizophrenia is not permitted unless psychotic symptoms persist for a substantial period of time after the person has stopped using the drug in question).

Concerns about potential stigma associated with having a serious mental illness have resulted in proposals to change the name of schizophrenia. "Integration disorder" and "dopamine dysregulation disorder" have been suggested as possible alternatives.¹⁰ Unfortunately, changing the name of the condition (or even abolishing the concept) will not affect the root cause of the stigma—the public's ignorance and fear of people with mental illness. Renaming may even have the unintended effect that the person, rather than the illness, is blamed for the symptoms.¹¹

Ultimately, we must gain a more complete understanding of the causes and pathophysiological mechanisms underlying schizophrenia. Only then can we replace the way we characterise schizophrenia with a diagnosis that more closely conforms to a specific brain disease. In the meantime, we can be confident and grateful that the benefits conferred by the concept of schizophrenia far outweigh any perceived disadvantages.

¹ Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, New York, NY 10032, USA

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Competing interests: JAL receives research grant support from Acadia, Bristol-Myers Squibb, GlaxoSmithKline, Merck, Organon, and Pfizer. MBF has received consultant fees from AstraZeneca, Abbott Laboratories, and GlaxoSmithKline and has been an expert witness regarding diagnosis of schizophrenia.

References

1. Boseley S. Call to wipe out schizophrenia as catch-all tag. Guardian, 10 October 2006.
2. Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry 2003;160:4-12.[Abstract/Free Full Text]
3. Kraepelin E. Psychiatrie: Ein Lehrbuch für Studirende und Ärzte. 4th ed. (Psychiatry: a textbook for students and physicians. 4th ed.) Leipzig, Germany: Abel, 1893.
4. Bleuler E. Dementia praecox, oder die Gruppe der Schizophrenien. (Dementia praecox, or the group of the schizophrenias.) Leipzig, Germany: Franz Deuticke, 1911.
5. Jakobsen KD, Frederiksen JN, Hansen T, Jansson LB, Parnas J, Werge T. Reliability of clinical ICD-10 schizophrenia diagnoses. Nord J Psychiatry 2005;59:209-12.[ISI][Medline]
6. McCormick LM, Flaum M. Diagnosing schizophrenia circa 2005: how and why? Curr Psychiatry Rep 2005;7:311-5.[Medline]
7. Andreasen N. The broken brain: the biological revolution in psychiatry. New York, USA: Harper and Row, 1984.
8. Lewis DA, Lieberman JA. Catching up on schizophrenia: natural history and neurobiology. Neuron 2000;28:325-34.[CrossRef][ISI][Medline]
9. Perkins DO, Gu H, Boteva K, Lieberman JA. Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. Am J Psychiatry 2005;162:1785-804.[Abstract/Free Full Text]
10. Sugiura T, Sakamoto S, Tanaka E, Tomoda A, Kitamura T. Labelling effect of Selshin-bunretsu-byou, the Japanese translation for schizophrenia: an argument for re-labelling. Int J Soc Psychiatry 2001;47:43-51.[Abstract/Free Full Text]
11. Penn DL, Nowlin-Drummond A. Politically correct labels and schizophrenia. A rose by any other name? Schizophrenia Bull 2001;27:197-203.[Abstract/Free Full Text]

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