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Renaming schizophrenia

BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39057.662373.80 (Published 18 January 2007) Cite this as: BMJ 2007;334:108

Rapid Response:

Renaming schizophrenia: open up the debate

Lieberman & First1 argue that schizophrenia should not be renamed
as it is a valid diagnostic category, it has many treatment options with a
sound evidence base and there are valid and reliable diagnostic criteria.
These assertions would not be disputed by the vast majority of those
working in mental health services. These are reasons, though, to keep the
diagnostic category rather than the name of it unchanged. They are quite
correct that the name is less important than its diagnosis or treatment.
However, many patients and carers are unhappy with the name.2

The main problem with the name, schizophrenia, is not that it is
‘politically incorrect’ but just incorrect. The concept of a ‘split mind’
is not supported by scientific advances and it is therefore unhelpful to
apply this concept to people with the disorder any more. The argument
that the name of a diagnosis has stood the test of time is no reason not
to modernise it. For example, in the ICD-10 the diagnosis of hysteria has
been replaced by categories of dissociative or conversion disorders.3 In
the UK the term mental handicap has been changed to learning disability by
the Royal College of Psychiatrists and the new term is now in popular
usage. Schizophrenia should not be exempt from the same processes.

Other interesting evidence that informs the debate about a possible
name change for schizophrenia comes from psychiatrists. According to
Clafferty et al4, psychiatrists don’t tell their patients the diagnosis
frequently enough. In a postal questionnaire they found only 59% of
psychiatrists informed their patients of a diagnosis of schizophrenia
after a first episode, and 15% said they would not use the term
schizophrenia. Moreover, 43% stated they felt uncomfortable about it and
10% felt it may harm the therapeutic alliance. In my own research, I
found further evidence that psychiatrists are cautious about telling a
patient their diagnosis of schizophrenia. In this qualitative study of
psychiatrists’ views about their practices, some stated that they opted to
preserve the therapeutic alliance by finding common ground or
circumventing the diagnosis, tried to minimise the impact of symptoms, and
exercised considerable judgement about the exact language and timing of a
discussion of diagnosis.5

It should be acknowledged that the stigma associated with
schizophrenia would not be abolished by a name change. This is supported
by a Chinese study.6 Students did not display any less stigmatising
attitudes to a vignette of a person with schizophrenia whether give a
diagnosis of schizophrenia, an alternative diagnosis or no diagnosis.
Conversely a label of schizophrenia generated more positive attitudes
amongst students with religious beliefs.

The issue of stigma is further complicated by patient’ own internal
working models. There can be a perception of stigma by people with mental
illness in addition to the actual attitudes expressed by other people.
This can lead to psychiatrists avoiding the term so as not to stigmatise
their patients. The avoidance of the term schizophrenia can lead to
alternative terms being adopted by patients and psychiatrists. Examples
are ‘Neuro Biochemical Disorder’ adopted by a patient2 and psychosis
commonly used by clinicians. It is therefore necessary to review all the
evidence for and against a name change rather than altogether rejecting
the idea or adopting an over zealous attitude to change.

The final difficulty is that schizophrenia describes a
characteristic, although very diverse, pattern of symptoms. This is in
contrast to the diagnoses of anxiety states, mood disorders, eating
disorders and learning disability where a central theme is generally
present with people who have the conditions. There is no obvious new
name, as illustrated by the many different names suggested by clinicians
and service users: the survey of names suggested by service users
described2 identified over 120 different ones. The participation of
people with schizophrenia is central to the debate about a possible name
change.

References

1. Lieberman JA, First MB. Renaming schizophrenia: Diagnosis and
treatment are more important than semantics. BMJ 2007;334:108

2. Berg SZ. Changing the S word: is there a better name?
Schizophrenia Digest 2006;Fall:30-34

3. World Health Organization ICD-10 Classification of Mental and
Behavioural Disorders. Geneva, Switzerland: World Health Organization,
1992

4. Clafferty RA, McCabe E, Brown K. Telling patients with
schizophrenia their diagnosis. Psychiatric Bulletin 2001;25:336-339

5. Chaplin R, Lelliott P, Quirk A, Seale C. Negotiating styles
adopted by consultant psychiatrists when prescribing antipsychotics.
Advances in Psychiatric Treatment 2007;13:43-50.

6. Chung KF & Chan JH. Can a less pejorative Chinese translation
for schizophrenia reduce stigma? A study of adolescents’ attitudes toward
people with schizophrenia. Psychiatry and Clinical Neurosciences
2004;58:507-515

Competing interests:
None declared

Competing interests: No competing interests

28 January 2007
Robert H Chaplin
Consultant Psychiatrist
Warneford Hospital, warneford Lane, Oxford OX3 7JX