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"Renaming" a panacea for stigma associated with mental illness...
- Rajeev Krishnadas (5 February 2007)
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Not Just Semantics
- Mark Agius, Marjeta Blinc Pesek, ,Brigita Novak Sarotar, and Marga Kocmur (7 February 2007)
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May be a good start
- Manfred Meister (13 February 2007)
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Rajeev Krishnadas, SHO Tranwell Unit, QE Hospital, Gateshead, NE10 9RW.
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The current trend is to rename everything. Patients are now called "service users", compliance is now termed "concordance". The list is endless and the process never stops. The study of medical students quoted by Kingdon et al (1), show that just renaming the illness wrongly led to a change in expectations of recovery, when actually there is no change in prognosis of the illness. Is this a good finding? or does it just show that the medical students need more training? I am worried that changing the name as in the study, would lead to more confusion as happened with the medical students and a false sense of security and false hope among carers and patients. And this could be more dangerous than we think. It is time we recognised and accepted that schizophrenia is a serious mental illness, with a not so good prognosis, at least in the developed world. And as doctors, we need to overcome the uncomfortable feeling of breaking bad news to the patient and relatives. As Leiberman and First (2) state in their editorial, the answer is, we need to be more active in psychoeducating the patients and the carers. There is no alternative to that, lest we keep trying to find short cuts and temporary measures to get rid of our responsibilities by just renaming everything. Reference: 1. David G Kingdon, Yoshihiro Kinoshita, Farooq Naeem, Maged Swelam, Lars Hansen, Selveraj Vincent, and Shanaya Rathod Schizophrenia can and should be renamed BMJ 2007; 334: 221-b-222-b 2. Jeffrey A Lieberman and Michael B First. Renaming schizophrenia BMJ 2007; 334: 108 Competing interests: None declared |
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Mark Agius, Associate Specialist Bedfordshire and Luton Partnership Trust, Marjeta Blinc Pesek, ,Brigita Novak Sarotar, and Marga Kocmur
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The suggestion by Kingdon et al that schizophrenia should be renamed [1] raises issues which are much more than semantic. Indeed, this suggestion challenges the latest findings of biological psychiatry. It is now likely that each case of psychotic illness is essentially a collection of syndromes, and that underlying these syndromes are a number of susceptibility genes which each have small effect, but whose presence or absence determines the form of the individual clinical illness. The consequence of this is that each individual psychotic illness lies on a spectrum with schizophrenia on the one hand and bipolar disorder on the other, the position of the individual illness being determined by the genes expressed in the individual patient, and by other environmental aetiological factors.[2][3][4][5][6] This model of psychosis takes into account the existence of forms of psychosis where little loss of grey matter occurs, and there are no cognitive deficits , as in bipolar disorder[7] and other forms of psychosis where, from very early on ,there is clear loss of grey matter and gradual development of cognitive deficits [8]. This latter form of illness is commonly referred to as schizophrenia, and represents a clear, subgroup of patients, which can represent at least 40-60% of cases in any population of psychotic patients. It is believed that this group of patients suffer from a neuro- developmental disorder , and Pantelis [9] has demonstrated that grey matter loss begins in this group very early on, including in the prodromal phase of the disease. Moller [10] has recently observed that in patients with poor outcome in schizophrenia, a neuro-progressive disorder supervenes on the neuro-developmental process which has been described. The suggested substitution of the terms ‘traumatic’ and ‘drug precipitated’ psychosis does not take into account the neuro-developmental processes described above . Furthermore, these two aetiological factors in psychosis are indeed very common, and stress and illicit drug use appear to be more likely to be ‘second hits’ which precipitate the illness, which was previously initiated by the first hit of the neuro-developmental process. Once definitively diagnosed, schizophrenia is a lifetime diagnosis, however proper early management , including treatment in the prodromal phase, appropriate medication, psycho-social interventions, identification and prevention of relapse, and psycho-education may enable a patient to manage his illness, and minimise long term sequaele. This must be described as ‘recovery’. Further proof that biological factors acting very early on in the development of the illness may have lasting effects, but that these effects can be modified by medication comes from a recent study [11]carried out by our team as a long term follow up of patients who had been treated in the prodromal phase of schizophrenia. Out of thirty-nine patients treated in the prodrome, four were eventually able to stop all medication, but , in the whole group, the number of chlorpromazine equivalents of medication used in the long term, the number of relapses and re-hospitalisations , and the employment status was statistically significantly better than a group of patients treated after a long duration of untreated psychosis. None-the-less, most of the patients who were treated in the prodrome continued to require some medication, even years later , indicating that a disease process was still present. The diagnosis of schizophrenia continues to describe a disease process, and the term should be retained, to describe the group of poor outcome patients with psychosis who we have described. References 1. Kingdon D et al 2007 Schizophrenia can and should be renamed BMJ334; 221 2. Harrison PJ 2006 Genes for psychosis: What do we know, what does it mean? Schizophrenia Research 86 ;S1 3. Craddock N Owen MJ 2005 The beginning of the end for the Kraepelinian Dicotomy Br J Psychiatry 186;364-366. 4. Craddock N, O’Donovan MC, Owen MJ. [2005] The genetics of schizophrenia and bipolar disorder: dissecting psychosis. Journal of Medical Genetics. 42;193-204. 5. Birchwood M 2006 Emotional Dysfunction in psychosis: a lost cause? Schizophrenia Research 86 ;S3 6. Okasha A 2006 The concept of schizoaffective disorder revisited [utility versus validity ] Proceedings First European Congress of the International Neuropsychiatric Association. Athens.p 7. 7.Curtis V, van Os J, Murray R. [2000] The Kraepelinian Dichotomy: Evidence from Developmental and Neuroimaging Studies. J Neuropsychiatry Clin Neurosci 12:3 ;398-405. 8 . Cannon M, Caspi A, Moffitt TE, Harrington H, Taylor A, Murray RM, Poulton R. [2002] Evidence for early-childhood , pan-developmental impairment specific to schizophreniform disorder; results from a longitudinal birth cohort. Archives of General Psychiatry 59[5]: 449- 456. 9. Pantelis C 2006 Brain MRI and Neuropsychological changes in psychosis; the Melbourne Longitudinal Studies Proceedings First European Congress of the International Neuropsychiatric Association. Athens.p 17. 10. Moller HJ 2006 Schizophrenia; from a neurodevelopmental to a neuroprogressive disease. Proceedings First European Congress of the International Neuropsychiatric Association. Athens.p 11. 11. Novak B 2006 PhD Thesis presented at the University of Ljubljana December 2006. Competing interests: None declared |
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Manfred Meister, Father Santa Rosa, CA
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As a real person who had a son with severe, treatment resistant paranoid schizophrenia I can atest to the fact that there is an ocean of misinformation and ignorance regarding chronic brain disorders in general and schizophrenia in particular. For example in recent newspaper article detailing the closure of the only public acute psychiatric facility in wealthy Sonoma County (aka wine country) the journalist discribe the clinics patients as being "disturbed". The term schizophrenia needs to be changed because: - the general public thinks it mean someone with multiple personalities - there are too broad a range of symptoms to be easily described by one term. My observation is that a true serious brain disorder will result in symptoms covering a range from psychosis, bi-polar and serious depression depending on which level of hell the person afflicted is currently experiancing. Competing interests: None declared |
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