“Schizophrenia” does not exist
BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i375 (Published 02 February 2016) Cite this as: BMJ 2016;352:i375
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J Van Os proposes to remove the term Schizophrenia and offers to broaden the entity. He challenges the utility and validity of the name, and questions the independence of Schizophrenia as a category.
The suggested substitutes ‘Psychosis Spectrum Syndrome’ and ‘Psychosis Susceptibility Syndrome’ need greater thought too. It remains debatable whether this cluster would sufficiently meet the original challenges. I argue here that elimination of the existing name does not solve the problems raised by the author.
His arguments and some replies:
1. Existing diagnostic categories do not qualify as discrete diseases.
This claim is valid as the current classificatory system remains a-theoretical and does not distinguish disorders based on underlying mechanisms or natural boundaries. Their origins and validity appear to be based on specific clusters of symptoms (observable experiences coming together in a certain pattern), distribution across time and observed outcomes. It is unclear that the alternatives proposed satisfy the ambition of being a condition that supports any definitive causal mechanisms.
2. The lack of validity (usually referring to ‘nature of reality’) of separate psychotic disorder).
There are good reasons not to take the validity of these disorders for granted. The utility for clinicians appear more established. Careful examination of validity does prove rather difficult to establish current psychiatric disorders as valid disease categories. Additionally, I agree that the category Schizophrenia maybe less valuable to scientists who research underlying mechanisms. (1)
Nevertheless, for the clinician it is challenging to combine clinical presentations such as an Acute Psychotic Episode or a Manic episode with Psychosis that are known to follow different clinical trajectories. Combining some of these presentations can lead to a different problem of having to grasp and explain the myriad of presentations of what we would call as the same illness. The author proposes to combine them as they appear to lie on a spectrum sharing some underlying vulnerabilities. Such a change would warrant descriptors and specifiers to delineate severity and prognosis. It would also warrant careful conditions and thresholds that mark the need for interventions.
3. The ‘un-understandable’ nature of the term Schizophrenia as a point that cancels its utility.
Elsewhere the author finds it unnecessary to use the name Schizophrenia based on underlying theory and indeed sub-clinical psychotic symptoms pointing to continuity with normal mentation. (2)
While the name Schizophrenia does require careful explanation, any substitute would also require appropriate education at the point of diagnosis.
4. The bleak prognosis that is now tagged to Schizophrenia and the stigma that surrounds it.
We shall do well to remember that Bleuler’s ‘Schizophrenia’ replaced Kraeplin’s ‘Dementia Precox’. Eugene Bleuler (1857-1939) modified significantly Kraeplin’s original concept. His Schizophrenia was not a clinical illness that deteriorated as suggested by Dementia Precox. Bleuler stated that schizophrenia “is not a disease in the strict sense, but appears to be a group of diseases [ ...] Therefore we should speak of schizophrenias in the plural.”(3) Indeed, the current ICD-10 Classification has Course specifiers that discriminate presentations that follow an episodic course with remissions and a more chronic course.
Will a broad category such as ‘Psychosis Susceptibility Syndrome’ necessarily help with the stigma that surrounds this illness?
Some of the other challenges around stigma and concrete understanding of the illness as a discrete genetically inherited brain disease can be addressed by careful formulation that is biopsychosocial in approach. Other ways would include appropriate and meaningful Psychoeducation amongst families, governments, the criminal justice system, fellow medical specialties and other stakeholders.
The proposal to transform Schizophrenia is a good opportunity to ask, ‘What is Schizophrenia?’
Historically viewed, the notion of schizophrenia crystallized itself as an end-achievement of successive phenomenological descriptions.
The question does not presuppose a commitment to realism about natural kinds (which is an issue raised by the author). It is prompted by clinical experience and based on the assumption that Schizophrenia displays a characteristic core Gestalt, conferring a certain typicality or prototypicality on its concrete clinical manifestations. This core Gestalt is understood to have a generative status that transpires into the diagnostically significant condition that we know. The essential trait dimension that marks Schizophrenia then presents with varying intensity and qualitative profiles. There is a need for a continuing debate and research on the boundaries of Schizophrenia. (5)
A famous passage from Dutch Psychiatrist, Rümke comes to our aid as he claims that certain hallucinations and delusions are diagnostic of schizophrenia, but only if they exhibit a certain characteristic schizophrenic taint; a tautological claim, which Rümke himself qualified as “a scientific absurdity”, yet absurdity “familiar to every experienced clinician”. (4)
Thus, it can be possible to accept and hold the heterogeneity that characterizes this illness whilst retaining its core element and name. This should enable us to challenge some of the problems presented, including preserving the validity of Schizophrenia.
References
1. Kendell R, Jablensky A: Distinguishing between the validity and utility of Psychiatric diagnoses. Am Journal of Psych 2003; 160(1):4-12.
2. Van Os J: 'Salience syndrome' replaces 'schizophrenia' in DSM-V and ICD-11: psychiatry's evidence-based entry into the 21st century?. Acta Psychiatr Scand. 2009 Nov; 120(5): 363-72.
3. Jablensky A: The diagnostic concept of schizophrenia: its history, evolution, and future prospects. Dialogues Clin Neurosci. 2010 Sep; 12(3): 271–287.
4. Parnas J: The core Gestalt of schizophrenia. World Psychiatry. 2012 Jun; 11(2): 67–69.
5. Jansson L, Handest P, Nielsen J, Saebye D, Parnas J: Exploring the boundaries of Schizophrenia: a comparison of the ICD 10 with other diagnostic systems in first admitted patients. World Psychiatry. 2002 Jun; 1(2): 109-14.
Competing interests: No competing interests
Chrys Muirhead describes how the label imposed on a person can blight their whole life and lead to unwanted and harmful 'treatments' and dehumanising, disempowering consultations. There are more enlightened health workers who will avoid using such a contested and stigmatising term, yet if the same person finds themselves, without any choice, referred to another with different views, the outcome can so easily be very damaging. In the past few decades several offensive labels, to say the least, have become taboo, for example Mongols/Mongoloid to describe people with Down's Syndrome; Spastics to describe people with Multiple Sclerosis; Manic Depression is now Bipolar; Idiots; Imbeciles; It is not only a matter of insensitivity and lack of empathy with those so labelled but has implications for coercive and degrading treatments which border on a breach of rights to be treated with respect and dignity. Even yesterday on R4 (which is running a week on mental health issues) a spokesperson from the college of psychiatrists described schizophrenia as a life long condition, without any qualification to educate the public that many people with such a diagnosis will become well again.
Psychiatrists, GPs and other health and social workers do not share an understanding of mental health conditions, have no knowledge of the person as a rounded human being with their own values and judgements of different options, and are less likely to consider anything than powerful drugs on repeat prescriptions. This is where qualitative projects in partnership with service users, health and social workers, and the public are helpful - but only if publicised and if they influence practice.
Competing interests: No competing interests
From Bleuler through to DSM-5 and ICD-10 schizophrenia has been ‘defined’ in terms of symptoms which are also unequally relevant to the other disorders van Os mentions. The idea of a direct correspondence of a word to a thing within this mix is about as helpful as the idea of a single schizophrenia gene. If the word schizophrenia does not equate to the ontological reality of the thing it signifies there remains a pertinent problem.
It may be that this discussion requires more than one point of view. From a research point of view the progressive sub-grouping, proposed by Professor Lawrie, may help. But in a clinical context DSM-5 just deleted the DSM-IV subtypes of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual types on the grounds of their unreliability. There seem to be different perspectives at play and not just one answer.
Competing interests: No competing interests
As a mother who has survived, and made a full recovery from, 3 separate episodes of psychoses, two of them postpartum in 1978 and 1984, the other menopausal in 2002, and the subsequent coercive psychiatric drug treatment (for I resisted the antipsychotics, preferring talking therapy which wasn't available), I agree with Prof Jim van Os's Article and concluding paragraph:
"The best way to inform the public and provide patients with diagnoses, therefore, is to forget about “devastating” schizophrenia as the only category that matters and start doing justice to the broad and heterogeneous psychosis spectrum syndrome that really exists."
I was given the diagnosis of schizoaffective disorder in 2002 which, even after my recovery, remains in my notes like a label. And I have family members who received the schizophrenia diagnosis/label. Resulting in "family history of ..." being written in the notes of any of us who happened to be treated for psychosis in the same health board area of Scotland. The schizophrenia and related diagnoses are very difficult to get erased from one's medical notes, regardless of recovery. In my case I tapered the drug cocktail in 2003, of Risperidone, Venlafaxine and Lithium, under my own steam. Stigma and discrimination, in my experience, are linked to the diagnoses and "family history of" assumptions.
Dr Lawrie writes of genes and increased risks however it is my understanding that the gene research is not conclusive. There are many ifs and buts. Not least the fact that long-term psychoactive drug treatment can disable the person neurologically and systemically. Parkinsonian side effects, problems with walking and balance, increased agitation and anxiety, loss of agency and ability to make decisions. I know about these, in the short term, having experienced the discomfort when having to take Chlorpromazine in the earlier treatment years and Risperidone later.
I was only on antipsychotics for a year maximum, with all 3 psychosis episodes, as I did not feel that I had quality of life on the drugs, they made me feel zombie-like. I know that other people may have different views and prefer medication. However for those of us wanting alternative therapies for psychoses or altered mind states the psychiatric diagnoses can exclude us from receiving psychological interventions. The psychiatrist may prefer using drugs, especially if they have links to pharmaceutical companies as consultants or "experts".
I do not agree with Dr Stephen Lawrie's closing paragraph:
"Just because a word like schizophrenia is mis-used does not mean it should be abandoned; and replacing it with something else of unproven value is likely to do more harm than good."
Schizophrenia is more than a "word" to the people who bear the label and live with the stigma, also their family members. It is a scapegoating term which has been used to separate some people from society, a form of alienation. Why should it matter to Dr Lawrie that the term be changed? Unless he has a lot invested in the matter. For when it comes to "unproven value" then that could be said of all psychiatric diagnoses. Which are only relevant at the time they are written down so as to "treat" a person/patient. People recover from "schizophrenia" and in their recovery prove the diagnosis wrong. What does cause "more harm than good" are the claims by psychiatry that the mind can be understood by science. They are clutching at straws and in so doing demonstrate the bankruptcy of their claims and positioning.
Competing interests: No competing interests
To state that schizophrenia does not exist is a trite assertion with no more meaning than saying, for example, that migraine does not exist. It would be equally meaningless to suggest that any abstract noun or concept does or does not exist. The key question is whether it is a useful concept, and even this may have to be asked within a defined context. (1)
The use of the term schizophrenia has allowed us to identify genes that increase risk, reproducible biological concomitants and, most importantly, treatments that are known to work from the results of clinical trials. (2-4) While schizophrenia has often been misrepresented, there is no strong evidence that doing away with the term is the solution. The ideas that schizophrenia always has a poor outcome and for which treatment at best ameliorative are just plain wrong. (5) Equally, however, we have to accept that about one-third of people with schizophrenia have a poor outcome. Changing the name of their condition won’t do anything to help those people. And to move towards having different terms around the world would be a retrograde step. It would be much preferable and more achievable to communicate more accurately about schizophrenia.
It would also be wrong to think no useful research is done on other psychosis categories. We know, for example, that most people with a brief psychotic disorder do not need ongoing treatment, (6,7) and that patients with bipolar disorder tend to respond to lithium, whereas those with schizophrenia do not. (8,9) Doing away with these diagnostic terms would simultaneously dispense with decades of clinical experience and research endeavour.(8) And for what? Because one of a number of vague alternatives may have a chance of reducing stigma? And what about the potential harms of such a conceptual change? To move to the less well defined runs the risk of increasing mis-diagnosis and losing what we already know about how to help patients in clinical settings.
The correct response to the heterogeneity of schizophrenia and the even greater heterogeneity of ‘psychosis’ is to study and to seek to progressively sub-group, building on accumulated wisdom. (9) This demands painstaking research. Just because a word like schizophrenia is mis-used does not mean it should be abandoned; and replacing it with something else of unproven value is likely to do more harm than good.
References
1. Kendell, RE. The role of diagnosis in psychiatry. Blackwell, Oxford: 1975.
2. Schizophrenia Working Group of the Psychiatric Genomics Consortium. Biological insights from 108 schizophrenia-associated genetic loci. Nature 2014; 511: 421-427.
3. Howes OD, Kambeitz J, Kim E, et al. The nature of dopamine dysfunction in schizophrenia and what this means for treatment. Archives of General Psychiatry 2012; 69: 776–786.
4. National Institute for Health and Care Excellence. Psychosis and schizophrenia: treatment and management. (Clinical guideline 178.) 2014. http://guidance.nice.org.uk/CG178].
5. Van Os J, Kapur S. Schizophrenia. Lancet 2009;374:635–645
6. Queirazza F, Semple DM, Lawrie SM. Transition to schizophrenia in acute and transient psychotic disorders. Br J Psychiatry. 2014;204:299-305.
7. Fusar-Poli P, Cappucciati M, Bonoldi I, et al. Prognosis of Brief Psychotic Episodes: A Meta-analysis. JAMA Psychiatry. 2016 Jan 13:1-10. doi: 10.1001/jamapsychiatry.2015.2313. [Epub ahead of print]
8. Lawrie SM, O’Donovan MC, Saks E, et al. From psychosis to psychoses: diagnosing psychotic disorders in the 21st century. Part 1 – Improving classification of the psychoses. Lancet Psychiatry, 2016 (in press).
9. Lawrie SM, O’Donovan MC, Saks E, et al. From psychosis to psychoses: diagnosing psychotic disorders in the 21st century. Part 2 - Towards diagnostic markers for the psychoses. Lancet Psychiatry 2016 (in press).
Competing interests: No competing interests
In his opinion paper, van Os posits that:
1. Schizophrenia is a heterogeneous syndrome, not a specific disease;
2. Expert opinions, diagnostic manuals, and clinicians cause patients to wrongly believe they have a devastating genetic illness;
3. Forming a single category “Psychosis Susceptibility Syndrome” including schizophrenia with a number of other psychosis categories will increase knowledge of understudied categories, while providing better information for persons with psychotic disorders.
4. Removing the term “schizophrenia” would reduce the effect of stigma.
We respond to his opinion on these four points below.
Point 1: We agree that schizophrenia (and most other psychotic disorders) are heterogeneous clinical syndromes but disagree on aspects of his critique and proposed solution. In order to come to individualized treatment, it will be key to explore underlying factors. In this way, the DSM-5 category is a starting point, not an endpoint.
Point 2: Van Os believes that diagnostic manuals such as DSM-5 reinforce a false view of schizophrenia as a devastating genetic disorder. We share the concern that professional and public perception often ignores the extensive data documenting a wide variety of courses including very good outcome in perhaps 20% of persons with schizophrenia. However, it should be noted that DSM-5 gives very specific emphasis to the syndromal status of psychotic disorders, provides symptom dimensions giving emphasis on what doctors need to know about patients, and that therapeutic targets lie beyond diagnostic categories.
Doctors and patients need to develop a shared view of illness and psychosis is no exception. Physicians are not entitled to withhold relevant information from patients. To inform a person with schizophrenia that they have a devastating genetic disorder would be harmful and misinformed. To withhold information on the chance for poor outcome would also be unethical. To explain to a person that many genes make small contributions to risk and that some 60-70% of variance is at the genetic level, but that these genes are also common in the population, provides a basis for discussion, not a pronouncement about the individual’s future.
The prognosis of schizophrenia can be devastating, but can also be rather good, as witnessed in many longitudinal course studies. Clinicians tend to see the latter group much less frequently than the first and may be inclined to give a too gloomy picture of expected outcome. Although Kraepelin’s original formulation viewed poor prognosis as central to dementia praecox, long-term follow-up studies have always demonstrated heterogeneity of course including good outcome. A very early example is the 40 years follow-up study that Manfred Bleuler performed of his father’s (Eugen Bleuler) patients. Registry and cohort studies show unbiased information about long-term mortality, employment rates and generally replicate good prognosis of a small, but significant, group across the globe (Holla et al. 2015; Yuen et al. 2014, Davidson et al. 2015). Most experts are well aware of these studies and report correctly on their findings to colleagues and patients. Perhaps some clinicians and the general public need to be better informed by these data and this is a challenge for public and professional education. More emphasis on remission and recovery may be needed, but it is certainly not established that clinicians routinely over-emphasize potential dire consequences of schizophrenia. In any case, prognosis assessment approaches have been available for over 60 years to assist clinicians and to inform patients that diagnosis is not fate.
Point 3. van Os’ suggestion that different categories of psychotic disorders, regardless of name, should be removed in favor of a single category comprising multiple psychoses diagnoses raises important problems. “Psychosis susceptibility syndrome” would increase the number of cases three to four fold resulting in between patient variability and within category heterogeneity that would challenge application of existing knowledge and confound future research with the problem already undermining less heterogeneous categories. In addition, there is meaningful validity to the current diagnostic categories. For example, lithium can be particularly beneficial in bipolar disorder, antipsychotic medication reduces relapse rates for most persons with schizophrenia, a schizoaffective disorder calls for explicit attention to mood disturbance as well as to psychotic symptoms, and brief psychotic disorders identify patients where long-term antipsychotic drug therapy is not indicated. To combine these various disorders in one group of “psychosis susceptibility disorder” will very substantially increases heterogeneity and confound interpretation of science at the level of clinical application.
Point 4. We agree that the proposed new name “psychosis susceptibility syndrome” has a more pleasant ring than current diagnostic terms. Changing the name is quite a rigorous way to improve the public’s and clinicians ideas about a disorder. A serious consideration of name change should be done with care, and not ad hoc. Preferably by the WHO, which can convene relevant experts and stakeholders and make a single decision with international implications rather than each country having their own nosology or name. Changing the word “schizophrenia” for a new term could be done without losing accumulated knowledge or changing future directions of clinical care or research. However, we do not know whether this would decrease stigma or make communication about the diagnostic category more informative. In Japan the translation of schizophrenia resulted in a very negative term and it was hoped that the name change would result in a more benign public perception. However, a recent report suggests that changing the new name in Japan has not appreciably changed public perception as represented in the media (Koike et al. 2015). The process of change has started at the single nation level and we believe it should quickly be addressed as an international issue. Yet the question here remains: will renaming be helpful?
To conclude: heterogeneity amongst people diagnosed with schizophrenia-related syndromes is high and this complicates individual treatment and research into new treatment strategies. The suggested even broader term “psychosis susceptibility syndrome” will make this problem even worse. If clinicians are insufficiently aware of this heterogeneity and if they provide too gloomy prognostic information, education is needed. However, it should first be investigated if this is indeed the case. Finally, whether a name change will improve stigma is not known.
References
Bleuler M, Huber G, Gross G, Schüttler R. [Long-term course of schizophrenic psychoses. Joint results of two studies]. Nervenarzt. 1976 Aug;47(8):477-81.
Davidson M, Kapara O, Goldberg S, Yoffe R, Noy S, Weiser M. A Nation-Wide Study on the Percentage of Schizophrenia and Bipolar Disorder Patients Who Earn Minimum Wage or Above. Schizophr Bull. 2015 Mar 20. pii: sbv023.
Holla B, Thirthalli J. Course and outcome of schizophrenia in asian countries: review of research in the past three decades. Asian J Psychiatr. 2015 Apr;14:3-12.
Koike S, Yamaguchi S, Ojio Y, Ohta K, Ando S. Effect of Name Change of Schizophrenia on Mass Media Between 1985 and 2013 in Japan: A Text Data Mining Analysis. Schizophr Bull. 2015 Nov 26. pii: sbv159.
Yuen K, Harrigan SM, Mackinnon AJ, Harris MG, Yuen HP, Henry LP, Jackson HJ, Herrman H, McGorry PD. Long-term follow-up of all-cause and unnatural death in young people with first-episode psychosis. Schizophr Res. 2014 Oct;159(1):70-5.
Affiliations:
Iris E Sommer is professor of psychiatry at the University Medical Center Utrecht, the Netherlands
William T. Carpenter is Editor-in-Chief for Schizophrenia Bulletin, and Chair of the DSM-5 taskforce for psychotic disorders
Competing interests: No competing interests
Prof Jim van Os is correct in his assertion that the various categories of “psychotic” illness we find in ICD-10 do not represent discrete diseases but rather describe clusters of symptoms or, if you prefer, overlapping syndromes.
He is also right to say that there is little evidence to distinguish schizophrenia (as defined in ICD 10) from the other “functional psychosis” by either aetiology or prognosis (despite the unfortunate the assertion he describes in DSM-5) and that the biologist’s preoccupation with the cause of “schizophrenia” may have undermined our understanding of the aetiology of most serious mental illness.
However he fails to consider that the term “psychosis” is as problematic and misleading as is the category “schizophrenia”. If the interested reader wishes to “google” this term they will find a myriad of descriptions of the cardinal features of this supposed condition. Some emphasise “impaired reality testing”, others describe an impaired ability to “perceive or interpret”,” while others emphasise “a radical change or disorganisation in personality”.
If the same reader examines ICD 10 or the DSM they will find some suffering “personality disorders” can show a radical change or disorganisation in personality, some suffering “eating disorders” seriously impaired reality testing, and some suffering serious “depression” an impaired ability to perceive or interpret.
Just as schizophrenia can not be properly distinguished from other psychosis, so psychosis can not be properly distinguished from other mental disorder. In my opinion the "diagnostic paradigm", so loved by most British psychiatrists (and American drug companies), is the issue here. We need a more radical approach. We should ditch our simplistic categorical systems and focus on historical narrative, objective symptom measurement and considered formulation of aetiology, prognosis, risk and capacity. Adolf Meyer, often regarded as the father of modern psychiatry, described this approach almost 100 years ago. Pity we didn’t listen.
Competing interests: No competing interests
I'm familiar with Jim van Os' work and find it of value in its contributions to questions beyond the day to day clinical issues which routinely dominate psychiatrists. For example, I find the arguments advanced by Burns, Crow, Horrobin and Nichols about the evolutionary basis of schizophrenia both fascinating and frustrating.
Fascinating in their inevitable conclusion that the schizophrenic are part of the neurodiversity (or whole body diversity as Horrobin would have it) of being human, frustrating because it is patently obvious that schizophrenia is an anachronistic concept when applied to pre-sub-Saharan diaspora of Homo Erectus/Sapiens. Schizophrenia didn't exist before Bleuler. The result is that as the scholars mentioned have overly privileged schizophrenia, the wider evolutionary contribution of the genetic propensity for psychosis is squeezed out of the discussion.
Jim van Os' approach provides a bigger, richer fuller idea of madness with a contribution to human development which is multi-dimensional not just 'bad'. This not only deconstructs the urge to pathologize madness (the inevitable consequence of focusing on the negatives and casting them in terms of mental illness) but loosen up the nosological propensity to confuse naming with understanding.
In an evolutionary context where madness is not mental illness and we are not always driven by the relentless negativity conjured by schizophrenia, the evolutionary advantages of psychosis to the human population can be considered in ways which are less bleak and more fecund .
Thanks Jim!
Burns, Jonathan Kenneth. "An Evolutionary Theory of Schizophrenia: Cortical Connectivity, Metarepresentation, and the Social Brain." Behavioral and Brain Sciences 27, no. 6 (2004): 831-55.
Crow, Timothy. "Aetiology of Schizophrenia", Current Opinion in Psychiatry 7, no. 1 (1994): 39-42. (and similar)
Horrobin, David F. The Madness of Adam and Eve : How Schizophrenia Shaped Humanity. London: Corgi, 2002.
Nichols, Catherine. "Is There an Evolutionary Advantage of Schizophrenia?" Personality and Individual Differences 46, no. 8 (2009): 832-38.
Competing interests: No competing interests
Heroic clinicians and pioneering researchers of the past, in dark superstitious ages, took a stand on evidence based diagnoses in order to better care for their patients.
They combined two ancient Greek words to express a complex new pathological concept, and used accessible scientific data of that era.
Nowadays it is easy, yet indecent, for us to criticize their nomenclature, based on recent scientific research.
Instead of indulging ourselves in pointless onomatopoeic exercises, we should wonder if we retain ourselves capable of ever discovering and describing a novel disease.
After all, even if “psychosis spectrum syndrome” might sound more appropriate today, many Agnostics and Materialists would still oppose the unfitting word "psychosis", since they doubt the presence of the soul (psyche).
Skeptics would opt for something like "telencephalic regional dysfunction".
Competing interests: No competing interests
Schizophrenia does exist : it is Kraepelin’s disease
Schizophrenia does exist : it is Kraepelin’s disease
We read with interest the personal view by Van Os with the provocative title ‘“Schizophrenia” does not exist’ with the subtitle “Disease classifications should drop this unhelpful description of symptoms”. On reading the article it appears that it would have been more aptly entitled “renaming schizophrenia.”
We support the case for the need to rename schizophrenia as highlighted by Lasalvia et al (1), in their review of the limited literature in the field, who proposed that the term schizophrenia should be abandoned given that the advantages outweigh the disadvantages overall. However the paper does emphasise that it is not just a change in name that is required but complex shifts in public perception, services, legislation along with the education of professionals to improve outcomes for this population. The authors hoped that the Work Group engaged in revising the psychoses for ICD – 11 would give careful attention to the term schizophrenia in view of the exceptional opportunity to remove the word from the public and professional vocabulary. Their review listed proposed terms to replace schizophrenia amongst which were Kraepelin-Bleuler disease and Bleuler’s Syndrome (1).
It was Emil Kraepelin in 1887 who differentiated the two main forms of psychosis namely ‘manic depression’ and ‘dementia praecox’. Kraepelin viewed ‘dementia praecox’ as mental disease with a deteriorating course and biological basis, a notion that has been supported by the extensive research demonstrating that it is a brain disease. However it was Bleuler in 1911 who introduced the name ‘schizophrenia’ to replace Emil Kraepelin's term ‘dementia praecox’. Bleuler stated, “I believe that the tearing apart (‘Zerreissung’) or splitting (‘Spaltung’) of the psychic functions is a prominent symptom of the whole group”. Morever he stated in his 1911 book, “I call dementia praecox ‘schizophrenia’ because (as I hope to demonstrate) the ‘splitting’ of the different psychic functions is one of its most important characteristics.”(2)
In view of the aforementioned, we support the use of medical eponyms and propose renaming schizophrenia, Kraepelin’s disease/syndrome. There are currently hundreds of medical eponyms in use and in neuropsychiatry, we still retain the eponyms Alzheimer, Parkinson, Wernicke, Korsakoff, Wilson and Down.
Concerning the renaming of the other related psychotic conditions such as schizoaffective disorder and schizophreniform disorders, these names could be dropped and replaced with the term psychosis.
Schizophrenia in its severe and chronic forms remains the “heartland of psychiatry “(3) and whilst the controversy over renaming it continues, it may outlive its obituarists!
Mohammed T Abou-Saleha and Helen L Millarb
a. Professor of Psychiatry, St George’s, University of London,United Kingdom
b. Consultant Psychiatrist, Department of Psychiatry, The Carseview Centre, Dundee, Scotland , United Kingdom
References
1.Lasalvia A., Penta E., Sartorius N., Henderson S. Should the label “schizophrenia” be abandoned. Schizophrenia Res 2015; 162:276-84.
2. Bleuler E. The prognosis of dementia praecox: the group of schizophrenias. In:Cutting J, Shepherd M, editors. The Clinical Roots of the Schizophrenia Concept: Translations of Seminal European Contributions on Schizophrenia. Cambridge, Cambridge University Press; 1987.
3. Goodwin, G. M., Geddes, J. R. The British Journal of Psychiatry 2007, 191 (3)
189-191.
Competing interests: No competing interests