Changing the name schizophrenia or reversing our research agenda?
The discussion on Lieberman and First’s (1) editorial appears to be
mainly focused on the semantic level (is the old term “schizophrenia”
consistent with our current understanding of this pathological condition?)
and on the pragmatic level (would renaming schizophrenia be of significant
and long-term help for destigmatisation purposes?).
However, another problem appears particularly important: is schizophrenia
a disease in its usual Western sense, namely a natural entity with a known
pathophysiology explaining its symptoms and allowing a differential
diagnosis from other diseases? Scientists working within the framework of
the neo-kraepelinian research program introduced operational criteria in
an attempt to improve reliability. They believed that this was the first
step in order to enucleate valid disease entities with distinct boundaries
whose underlying etiology would be later discovered (2). What is now clear
is that “in the more than 30 years since the introduction of Feighner
criteria by Robins and Guze, which eventually led to the DSM-III, the goal
of validating these syndromes and discovering common etiologies has
remained elusive” (3). Accordingly, the current categorial classification
entered a period of crisis and revolutionary systems of classification are
waited (4,5). In this context it is not surprising that schizophrenia does
not represent a single disease entity (it was a group of conditions since
the beginning (6)), that its boundaries are unclear and that we cannot
reasonably expect to find a unique etiology underlying all cases.
Lieberman and First (1) acknowledge the diagnostic limits of the concept
of schizophrenia, nevertheless they continue to adhere to the neo-kraepelinian research program and to think about schizophrenia as a brain
pathology. Similarly, Ahuja and Cole (7) correctly argue against the
possible name “dopamine dysregulation disorder” but they write that it is
so because there is more than dopamine that is dysregulated in
schizophrenia, stressing “a peril of plethora of names emerging for the
same condition”. But it is this the most problematic point: schizophrenia
is not a disease but a general label under which many different clinical
conditions are probably subsumed. Therefore the key point is not to give a
new name to schizophrenia but to reverse our research agenda: we should
not start from the diagnosis of schizophrenia to test etiological
hypotheses, because it is unlikely that a common brain pathology may be
discovered starting from a heterogeneous and “fuzzy-boundaries” category.
On the contrary, it would be preferable to start from known specific
functional abnormalities and then try to explain the pathophysiological
mechanisms linking these abnormalities to emerging symptoms (4). If
research succeeds in achieving this aim the classical schizophrenia would
be progressively dismembered in new entities and the problem of changing
its name will naturally disappear.
2. Klerman GL. A debate on DSM-III: the advantages of DSM-III. Am J
Psychiatry 1984; 141: 539-542.
3. Kupfer DJ, First MB, Regier DA. Introduction. In: DJ Kupfer, MB
First, DA Regier (eds) A research agenda for DSM-V, pp XVIII. Washington
DC: American Psychiatric Association, 2002.
4. Aragona M. Aspettando la rivoluzione. Il DSM-V e oltre: le nuove
idee sulla diagnosi tra filosofia della scienza e psicopatologia. Roma:
Editori Riuniti, 2006.
5. Aragona M. A bibliometric analysis of the current status of
psychiatric classification: the DSM model compared to the spectrum and the
dimensional diagnosis. It J Psychopat 2006; 12: 342-351.
6. Bleuler E. Dementia praecox: or the group of schizophrenias.
(trans. By J. Zinkin). New York: International Universities Press, 1950.
Rapid Response:
Changing the name schizophrenia or reversing our research agenda?
The discussion on Lieberman and First’s (1) editorial appears to be
mainly focused on the semantic level (is the old term “schizophrenia”
consistent with our current understanding of this pathological condition?)
and on the pragmatic level (would renaming schizophrenia be of significant
and long-term help for destigmatisation purposes?).
However, another problem appears particularly important: is schizophrenia
a disease in its usual Western sense, namely a natural entity with a known
pathophysiology explaining its symptoms and allowing a differential
diagnosis from other diseases? Scientists working within the framework of
the neo-kraepelinian research program introduced operational criteria in
an attempt to improve reliability. They believed that this was the first
step in order to enucleate valid disease entities with distinct boundaries
whose underlying etiology would be later discovered (2). What is now clear
is that “in the more than 30 years since the introduction of Feighner
criteria by Robins and Guze, which eventually led to the DSM-III, the goal
of validating these syndromes and discovering common etiologies has
remained elusive” (3). Accordingly, the current categorial classification
entered a period of crisis and revolutionary systems of classification are
waited (4,5). In this context it is not surprising that schizophrenia does
not represent a single disease entity (it was a group of conditions since
the beginning (6)), that its boundaries are unclear and that we cannot
reasonably expect to find a unique etiology underlying all cases.
Lieberman and First (1) acknowledge the diagnostic limits of the concept
of schizophrenia, nevertheless they continue to adhere to the neo-kraepelinian research program and to think about schizophrenia as a brain
pathology. Similarly, Ahuja and Cole (7) correctly argue against the
possible name “dopamine dysregulation disorder” but they write that it is
so because there is more than dopamine that is dysregulated in
schizophrenia, stressing “a peril of plethora of names emerging for the
same condition”. But it is this the most problematic point: schizophrenia
is not a disease but a general label under which many different clinical
conditions are probably subsumed. Therefore the key point is not to give a
new name to schizophrenia but to reverse our research agenda: we should
not start from the diagnosis of schizophrenia to test etiological
hypotheses, because it is unlikely that a common brain pathology may be
discovered starting from a heterogeneous and “fuzzy-boundaries” category.
On the contrary, it would be preferable to start from known specific
functional abnormalities and then try to explain the pathophysiological
mechanisms linking these abnormalities to emerging symptoms (4). If
research succeeds in achieving this aim the classical schizophrenia would
be progressively dismembered in new entities and the problem of changing
its name will naturally disappear.
1. Lieberman JA, First MB. Renaming schizophrenia. BMJ 2007; 334:
108.
2. Klerman GL. A debate on DSM-III: the advantages of DSM-III. Am J
Psychiatry 1984; 141: 539-542.
3. Kupfer DJ, First MB, Regier DA. Introduction. In: DJ Kupfer, MB
First, DA Regier (eds) A research agenda for DSM-V, pp XVIII. Washington
DC: American Psychiatric Association, 2002.
4. Aragona M. Aspettando la rivoluzione. Il DSM-V e oltre: le nuove
idee sulla diagnosi tra filosofia della scienza e psicopatologia. Roma:
Editori Riuniti, 2006.
5. Aragona M. A bibliometric analysis of the current status of
psychiatric classification: the DSM model compared to the spectrum and the
dimensional diagnosis. It J Psychopat 2006; 12: 342-351.
6. Bleuler E. Dementia praecox: or the group of schizophrenias.
(trans. By J. Zinkin). New York: International Universities Press, 1950.
7. Ahuja N, Cole AJ. What’s wrong with the term “Schizophrenia”?
Rapid response to Lieberman and First.
http://www.bmj.com/cgi/eletters/334/7585/108
Competing interests:
None declared
Competing interests: No competing interests