The differences in the diagnosis of schizophrenia and what it has meant
culturally is probably an essay all in itself.
Culture matters.
The latest fashion comes from Japan. They relabelled schizophrenia and
reconeptualised it to something like social integration disorder. The
shift away from what Bleuler meant is significant. After all, words have
power according to some studies.
There are complex cultural reasons why this makes sense and they are
explained by this excellent paper that's well worth a read.
Impact of the Term Schizophrenia on the Culture of Ideograph: The
Japanese Experience
Yoshiharu Kim and Qerman E. Berrios
http://schizophreniabulletin.oxfordjournals.org/cgi/reprint/27/2/181-a.pdf
To most people in the West the word "schizophrenia" means nothing unless
you know Greek whereas "bipolar disorder" can have meaning to the
uninformed lay person because the idea of two poles can be taken from
the words. "Extremes of mood disease" could be a relabelling of bipolar
disorder if the aim was to help communication of the concept to the lay
person. I am unaware of the impact on outcomes on the relabelling of
manic depression to bipolar.
The Chinese ideograph for schizophrenia directly expresses the meaning
as "the disease of disorganized mind" to a person without psychiatric
knowledge. That in itself is a reasonably accurate interpretation of one
facet of what people with a diagnosis of schizophrenia look like upon
external observation. However the Japanese ideograph
(seishin-bunretsu-byo) means "mind-split-disease" which is similar to
the most commonly cited explanation of the Western translation of the
word schizophrenia. There are undertones to the word and the individual
lexical components which combine to make a highly stigmatising word in
that culture and one that is immediately understood from looking at the
word. "Catastrophe of the mind" is one of the lay connatations in China
and Korea. The stigma in Japanese culture is significantly higher and it
is inbound in the word itself.
The paper explains that this is why their is a priority for a name
change int he East and the situation is significantly different from the
West.
The term schizophrenia has lasted for over a century. In that time the
intepretation of schizophrenia has changed. The advance of the
sociological model of mental illness means that the new word is about
lack of integration with society and implicitly with local culture. This
could explain the overdiagnosis of schizophrenia in black men as much as
racism.
However it is the current fashion. In 30 years there will be a new
interpretation. In fact there are already competing paradigms in the new
words to be chosen for use in the West. I can't remember the new term
suggested - something like post trauma psychosis - which is based on
professor Marius Romme's work and the work of the Hearing Voices
Network. It is a different interpretation from Bleuler and the Japanese
and is from a psychosocial paradigm or predominantly psychological paradigm.
The new label is being hewn from the rocks of academia but these haven't
settled on a consensus. Instead they're creating new terms that are
different around the world in a time when there was talk of unity
between DSM and ICD. These new terms won't last 30 years let alone a
century because they are linked to the different understandings.
If the goal is the most positive outcomes for patients then the
relabelling should be considering alternatives like "disease which is
only has bad outcomes because doctors are idiots and don't listen to
patients" which would quickly solve the problem of doctors assessment of
poor outcomes for this condition. It could be called "artists and saints
disease" which again would put a positive spin on the term and would be
a great propaganda message. "Spiritual crisis" and "ego death" are
already terms which relabel and reconceptualise the experience.
These terms also have much more chance of withstanding the changes in
fashion in world psychiatry.
The paper also refers to the original book by Bleuler and how he
described what he saw as schizophrenia. It means splitting of the
psychological functions and has a different meaning to the splitting of
the mind in my opinion though I'm sure even this evidence will not be
enough to make the point that people seem lost in etymology and
semantics when they should be looking at concepts and better 'treatments'.
"
Is the "split mind" metaphor still relevant? The history of
this metaphor is rather important and will be briefly mentioned.
Bleuler (1911) wrote, "In each case there is a more
or less clear splitting of the psychological functions: as
the disease becomes distinct, the personality loses its
unity" ("In jedem Falle besteht eine mehr oder weniger
deutliche Spaltung der psychischen Funktionen: ist die
Krankheit ausgesprochen, so verliert die PersOnlichkeit
ihre Einheit")
"
It also mentions other past failed neolgisms other than social
integration disease and post trauma psychosis.
"
intrapsychic
ataxia, dementia dessecans, discordance, dementia sejunctiva,
dysphrenia, discordance, and so forth. None ever
caught on (Berrios 1987).
"
Signficantly to me the paper explains
"
Its introduction into
American psychiatry (by DSM-IH, American Psychiatric
Association 1980) led to a gradual abandonment of the
Bleulerian view.
"
This is a good reason to change the name.
This last bit is really interesting and says it better than I can
"
A new name could be constructed on the basis of (1)
a fundamental biological mechanism, (2) a pathognomonic
clinical feature, (3) a crucial psychological dysfunction,
or (4) an eponym. Bleuler wished that it was
option 1 but in the end settled for 2. The problem today is
that there is not yet a scientific conclusion about either the
disease's fundamental biological mechanism or its
pathognomonic clinical feature. In regard to option 3,
Kraepelin regarded dementia praecox as primarily a disorder
of intellectual function (as opposed to manic-depressive
illness, which was primarily a disorder of affect), and
the field is now going through a "cognitive period" in the
interpretation of the disease (e.g., Andreasen 1999).
However, grouping schizophrenia with the many dementias
currently described might be confusing, and a redefinition
of "cognition" in the future might leave many with
egg on their face. It would seem, therefore, that our scientific
ignorance precludes 1, 2, and 3 above.
What about 4? Eponyms are safe in that they are
proper names and avoid connotations altogether. History
shows that the disease was mainly identified by Kraepelin
and Bleuler. "Kraepelin's disease" already exists to name
a form of presenile dementia, and "Kraepelin-Morel's disease"
and "Bleuler's disease" (Morbus Bleuler is the original
term and is used in some parts of Germany) never
took off. "Bleuler's syndrome" already exists to name a
form of "organic delirious state." Under the circumstances
and provided that we all believe that schizophrenia will
survive as a unitary disease for the next 50 years, we may
want to rename schizophrenia "Kraepelin-Bleuler disease,"
or KBD for short.
"
A more difficult solution is to individualise diagnosis such that every
person has a diagnosis based on their name. So Stephen Fry didn't have
bipolar. He had "Stephen Fry of QI disorder." This is a ridiculous
concept on first appraisal however the state of science in the
psychiatric system and clinical practice means it is as useful to
classify a person as an individual with an individual experience of
life, an individual prognosis and response to treatment. It makes things
harder for psychiatrists to practice medicine but it solves the problem
of the stigma of labels, poor outcomes for conditions that are hard to
'treat' and encourages more openminded thinking.
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