IN 2002 THE JAPANESE Society of Psychiatry and Neurology changed the official name of ‘schizophrenia’ (seishinbunretsu-byo, split mind disease) to a term meaning ‘loss of coordination disorder’ (togoshitcho-sho.).1 This was officially recognized by the Japanese Ministry of Health and Welfare in 2005, and the former term is now no longer in use.2 The effect of merely changing a possibly stigmatic term to something new may be moot, yet there has been discussion on whether a change in the English terminology would be clinically, socially and scientifically desirable. Ono and Nishimura reported that informed consent became much easier after the renaming of schizophrenia in Japanese.3 Sato also reported that the new term was implemented immediately after the name was changed.4,5 The objective of the present study was to investigate whether there is the same movement internationally or not, and how the experts in different countries are thinking about the name ‘schizophrenia’.
Some psychiatric diagnoses are stigmatic. In August of 2002, at the annual congress of the Japanese Society of Psychiatry and Neurology, the Society decided to change the name of schizophrenia in Japanese from seishinbunretsu-byo (‘split mind disease’) to togoshitcho-sho (‘loss of coordination disorder’). In 2006 a survey was carried out among the 80 members of the Section on Classification, Diagnostic Assessment and Nomenclature of the World Psychiatric Association. Of the 21 responding, nine (45%) did not think that ‘schizophrenia’ was an appropriate term for the disease and half thought that the term ‘schizophrenia’ had a stigmatic meaning.
To attempt to gain insight into the thinking concerning this point among international psychiatric authorities we carried out a questionnaire in 2006. In addition to sociodemographic information, our questionnaire included other questions and spaces for comments, and these are listed in Table 1.
|1. How long have you worked as a psychiatrist?|
|2. Do you use the term ‘schizophrenia’ or its equivalent in your language when you explain the diagnosis to the patient?||10||7||2|
|3. If you do not use the word ‘schizophrenia’, please write the term you use and which language it is.|
|4. Do you think that the term ‘schizophrenia’ is an appropriate term for the disease?||11||9|
|5. Do you think that the term ‘schizophrenia’ has a stigmatic meaning?||10||6||3|
|6. If you answered ‘Yes’ to No.5, should ‘schizophrenia’ be changed to another term to reduce stigma?||6||4|
|7. In your language, is the term ‘schizophrenia’ concordant with the meaning of ‘split-mind disease’?||13||6||1|
|8. In your country or in your main psychiatry society, is there any action or movement to change the term ‘schizophrenia’?||2||17||1|
|9. If you answered ‘Yes’ to No.6, please indicate when it will be changed?|
|a). As soon as possible||2|
|b). By the ICD-11||3|
|10. If you answered ‘Yes’ to No.6, what term is appropriate instead of the term ‘schizophrenia’? Please write your suggestions below.|
|11. Do you think that the terms ‘schizoid’ and ‘schizotypal’ also should be changed?||6||13|
|12. On question 11, if you answered ‘Yes’, what terms are appropriate instead of the terms ‘schizoid’ and ‘schizotypal’? Please write your suggestions below.|
This questionnaire was sent to 80 members of the Section on Classification, Diagnostic Assessment and Nomenclature of the World Psychiatric Association using the 2006 members list. We sent a questionnaire by email and, if email addresses were not identified, by hard copy.
Twenty one (26.3%) responded, from Kenya, Nigeria, Egypt, UK, Switzerland, Germany, Czech Republic, Italy, South Korea, Japan, USA, Canada, Nicaragua, Cuba, Brazil and Argentina. The mean length of careers of the respondents as psychiatrists was 32.0 ± 14.0 years).
The results are shown in Table 1. One respondent was not included because he only gave comments regarding the renaming of schizophrenia. The reason why the total numbers in Table 1 did not reach 20 in questions 2, 5 and 11 is because some respondents did not answer all the questions. The most remarkable finding was that nine respondents (45%) answered ‘No’ to question 4 (appropriateness of the term ‘schizophrenia’). In addition, half of the respondents considered that the term ‘schizophrenia’ had a stigmatic meaning. Among them, six (60%) agreed on the need for a name that reduces the stigma.
As alternative terms for schizophrenia, the following suggestions were proposed: integration disorder, integrative disorder, disintegrative disorder, schizophrenic syndrome, non-affective psychotic disorder, detachment syndrome with dissociative features, ‘flat’ psychosis, monoamine dysregulation disorder, connecting disorder, chronic detachment syndrome, multi-symptomatic psychosis and processing disorder.
In contrast, as alternative terms for schizoid they suggested introvert, isolation or pseudo-dissociative, while for schizotypal they suggested odd or eccentric or post-detachment.
The reason for the renaming of schizophrenia in Japan was that the term ‘schizophrenia’ (seishinbunretsu-byo, split mind disease) had an image of a totally untreatable illness and consequently it then tended to cause secondary illnesses. In addition, it made it difficult to inform patients about their diagnoses. The stigma concerning schizophrenia has been around since the time of ancient Greece, and continues today. The World Psychiatric Association is carrying out an anti-stigma campaign.6 Of course, it will be impossible to completely erase the stigma by renaming it, but at least it is likely to become easier to inform patients about their condition. In Japan, the image of schizophrenia as an untreatable illness is now less strong than before, and renaming it seems to favorable, at least to families of patients.7
The results of this survey were obtained from only 21 experts, although they were from throughout the world. Several reasons may be proposed regarding the poor response, but we speculate that the most likely are the sensitivity of the topic, the busy lives of those approached, and perhaps a feeling that a questionnaire does not allow them to express finely nuanced thoughts. Approximately half, however, thought that the term ‘schizophrenia’ had a stigmatic meaning. Moreover, 60% of them replied that ‘schizophrenia’ should be changed to another term in order to reduce stigma. Because of the small number of respondents, although they had much experience as psychiatrists, we cannot conclude whether renaming is necessary or not. Of course, as Liberman and First pointed out, we must gain a complete understanding of the underlying causes and pathophysiological mechanisms.8 There has, however, been no previous survey like this about the renaming of schizophrenia throughout the world, thus we believe that the present survey has a certain value. We think that more useful information could be obtained if further surveys could include doctors, patients and families worldwide. The present respondents are not official representatives of their countries or academic societies. Their opinions are personal. Approximately half of the respondents, however, agreed that the term ‘schizophrenia’ had a stigmatic meaning.
In addition, in the comment section of this questionnaire, all experts wrote individual comments. Many respondents emphasized that reducing stigma is necessary as an educational approach adjunct to renaming. The anti-stigma campaign is becoming increasingly well-known, and it is also being studied by the Japanese Government,9 but more effective methods are necessary to reduce the stigma worldwide.
Finally, we would like to note the survey had limitations because the experts we asked were not official representatives of their respective countries, as aforementioned. Before deciding to change the name of schizophrenia, a more extensive worldwide survey is necessary.
The authors would like to thank Drs C. E. M. Banzatto, G. Bartocci, A. Binitie, E. D. A. Busnello, J. T. Caldera-Aburto, B. Campbell, J. E. Cooper, K. W. M Fulford, H. Helmchen, Y. Honda, J. E. Mezzich, D. M. Ndetei, A. Okasha, L. A. Opler, A. Otero, C. Pouncey, B. N. Rhi, I. M. Salloum, N. Sartorius, A. N. Singh, P. Smolik, R. O. Testa, and L. A. B. Villano. The authors are indebted to Professor J. Patrick Barron of the International Medical Communications Center of Tokyo Medical University for his review of this manuscript.