Introduction

Schizophrenia is one of the most controversial disorders for mental health researchers and all scientists around the world, because it is a disease of unknown etiology due to the complex interactions of genetics and environmental factors. According to Rodríguez-Pulido & González [1], schizophrenia historically has represented the paradigm of insanity, and innumerable theories have been developed to explain the origin of it.

The first classification of mental disorders came from Hippocrates (460-370 BCE) in Greece, and it remained until Galen (129-201 CE), Kant (1724-1804), reaching Philippe Pinel (1745- 1826) [2]. Pinel, considered the founder of psychiatry, inspired by botanist and zoologist Boissier, established the principles of classification of mental illnesses. Later, Esquirol, Falret and Baillager contributed to the history of the concept “schizophrenia” with denominations such as: Dementia, Circular insanity, and Double-form insanity, to explain what Kahlbaum and Hecker would later call Catatonia and Hebephrenia respectively [3].

Hecker’s and Kahlbaum’s descriptions allowed the German psychiatrist Emil Kraepelin to propose the concept of Dementia praecox as a disease, under the description of a deterioration process (Verblödungsprocesse) in his 6th edition of “Lehrbuch” in 1899. In this work, he established four large groups of endogenous and evolutionary psychoses. Previously, Morel in 1860 used the term Démence précoce for the first time, but the use of this concept by Kraepelin was much more ambitious and systematized [4]. In 1911 the psychiatrist Eugen Bleuler who considered himself an adept of Sigmund Freud’s ideas, published a document entitled: “Dementia praecox oder Gruppe der Schizophrenien”, where he characterized this disorder as the splitting of the self with the neologism “schizophrenia” (split mind). The Spaltung (split) was what defined the schizophrenic process [4]. The idea of a divided, fragmented or split mind, which meant the rupture of the inner unity, has been expressed before in numerous times in Freud´s theory [5].

In addition, Bleuler described four fundamental symptoms (Bleuler 4 a’s) that included disorders in areas like: association, affective, ambivalence and autism. These were exclusive of schizophrenia, which could also present other secondary symptoms such as: hallucinations, delusions, memory and language impairment [5]. Later in 1946, Kurt Schneider inverted Bleuler’s fundamentals and secondary symptoms and gave greater relevance to hallucinations and delusions as first-rank symptoms, considering the loss of the limits between the self and the world as the main description of the illness [5].

After the Second World War (WWII), The Diagnostic and Statistical Manual of Mental Disorders (DSM) was published in its first edition in 1952. DSM-I was the first official manual with clinical utility published as a compilation of ICD-6 (1948), made by Meyer and Menninguer [2]. One of the most important diagnostics related with the term of schizophrenia, was “Schizophrenic Reactions” that were conceivable as reflections of the personality to biological, social and psychological factors (n/a, s.f.). In DSM-II (1968), the “Schizophrenic reactions” were changed to: “chronic and latent types of schizophrenia”. In addition, these types of schizophrenia were defined as a group of disorders that included for the first time: cognitive, emotional, and behavioral disturbances. Schizophrenia in childhood was introduced too as a possible diagnostic. At that time, Guze, Robins and Feighner (a group of scientists known as the neokraepelinians) published an operational set of criteria for the diagnosis of schizophrenia, that Spitzer considered important for the publication of DSM-III [3].

In the third edition of DSM (1980), the disorder was renamed to “Schizophrenic Disorder”, where the role of hallucinations, delusions, and thought disturbances were highlighted. In addition, impairment of functioning is introduced as a second important diagnostic element, and current episode and the course of the disease for the diagnosis were added (n/a, s.f.). In DSM-IV (1994) the three previous sections of DSM-III related to psychotic disorders are gathered under only one chapter named “Schizophrenia and other psychotic disorders”. The required duration for the symptoms of active phase was increased from one week to one month, and the negative symptoms (alogia and abulia) were included to simplify the definition of the prodromal and residual phases. DSM-5 (2013) did not have important modifications regarding the understanding of this disorder in its diagnostic criteria.

The concept of schizophrenia as its mentioned in DSM and ICD, is increasingly being questioned for its lack of validity in terms of signs, symptoms, evolution and heritability. Experts are considering how to rethink this concept, in the absence of knowledge about physiopathological and etiological mechanisms, by integrating advances in fields like genetics, molecular biology, brain imaging and cognitive sciences [6]. This term has been even questioned as a psychiatric illness. An example of this, it is the Thomas Insel proposal, psychiatrist from the NIMH of Maryland, that has questioned the concept of schizophrenia understood as a mental disorder. He claims that all actual evidence point at a new understanding of it as “a neurodevelopment disorder with psychosis as a late and potential preventable stage of the illness” (p. 190). He supports the idea that schizophrenia should not be understood as a psychiatric illness anymore, but a neurodevelopment disorder [7].

Insel considers that schizophrenia it is a neurodevelopmental illness that has four stages. The first one involves all the risk variables prior to symptoms appearing (genetic vulnerability, environmental exposure). The stage two includes pre-psychotic prodrome symptoms defined by changes in thoughts, social isolation, and impaired functioning. The stage three could be understood by the manifestation of psychosis (hallucinations, delusions, disorganizations of thought, behavior and psychomotor abnormalities). Stage four could be characterized as the chronic disability [7]. Furthermore, Doctor Brian Kirkpatrick from Medical College of Georgia sustained since 2009 that schizophrenia is not a psychotic disorder. It is a developmental disorder with abnormalities in many functions. Also, he claims that schizophrenia is not a brain disease. It is a developmental disorder that affects other parts of the body besides the brain (p. 106).

The interest of this article is not to promote a specific proposal of any specialist on schizophrenia. The personal interest of this devising is to motivate the reflection on the possibility of abolishing the use of the term schizophrenia for the following reasons: the high stigmatizing implications of the term that exclude, defame and violate the lives of people with this stigmatizing diagnosis and their families, who have been humanely invisible for more than a century. Therefore, we should consider reviewing a term that has not changed in more than 110 years, while terms for other psychopathologies have shifted. The term schizophrenia, etymologically describes an imprecision currently evidenced by scientific advances, and is full of stigmas that exclude, defame and violate the lives of people with this diagnosis, who have been invisible for all of us more than a century.

The American Psychiatric Association (APA) historically have dropped from DSM terms as: neurotic, homosexuality, imbecile, mental retardation, Asperger, and hebephrenia, among others, for being cataloged imprecise or stigmatizing. So, maybe it is time to drop this highly stigmatizing term, that embodies concepts like dangerousness and non-recoverability [8]. That stigma, “too often defines a person rather than describing the illness” [7] and those misunderstandings had labelled people with this disorder wrongly. As Colordón [9] refers, schizophrenia does not describe a process that is suffered by individuals, but a condition that permeates the whole existence of those who suffer from it.

It is difficult to find a current illness with some parallel with schizophrenia [10]. Authors like Casco et al. [11] and Thompson et al. [12] among others, has mentioned that stigmatization suffered by these people is attributed to the idea of unpredictability and dangerousness than to a scientific reality. Wahl & Harman found that the main source of stigma came from: films, newspapers and even jokes about “insanity” [13], in other words, to the cultural agreements about this disease. This term can be traumatic for many who have to face it, and are everyday socially isolated, feared and rejected. Many clinicians even treat these persons inappropriately because they might suppose that there is no help for them [8].

A few countries have already stopped using the term “schizophrenia”. In 2002, Japan replaced the term with “integration disorder” and all evidence indicates that this change led to reduced stigma [7]. Also, South Korea changed the concept to “attunement disorder”, and Hong Kong and Taiwan to “cognitive-perceptual dysfunction” [8]. Even institutions like The International Society for the Psychological Treatments of the Schizophrenias and other Psychoses (ISPS) since [14] are making decisions to modify the name of this honorable and distinguished association, and remove the term schizophrenia of the full name of ISPS.

The semantic changes can be helpful, but a better term for the diagnosis should allow specialists to practice a better science too [7]. A renewal of the concept would necessarily have an impact on the medical care for the people who suffer from it [6]. However, before the World Health Organization (WHO) validates the use of ICD-11 in 2022, and influences the pertinent changes for a possible revision of DSM-5 by APA, a serious academic fight must take place for the rights of people with schizophrenia and their families, who are commonly silenced and not considered. It is too difficult to fight for recovery and integration into society when all the bets are against them [15].

It is valid that researchers and specialists focus almost all of their studies to find better therapies for this disorder, or alternatives that displace, for example, the dopaminergic theory for a Glutamate one. However, we should be aspiring to put bioethics ahead. Scientists around the world should speak up to improve the quality of life for people with schizophrenia. Before being subjects of experimentation, they are individuals with human rights, and if we pay attention to their voices, we could improve our awareness about the pain that this condition generates in their lives, and the social, affective, labor, and medical discrimination they suffer. They are the ones facing limited opportunities as they strive for a full life [16].

It is my hope that this article can add to the global conversation about removing the term schizophrenia from our vocabulary, and that this conversation includes not only the academic and scientific community, but also the general public, people with this condition, and their families [17].

References

1. Rodriguez-Pulido F, Gonzalez de Rivera JL (1993) The epidemiological investigation of schizophrenia: some methodological problems. In The epidemiological method in Mental Health. (La investigación epidemiológica de la esquizofrenia: algunos problemas metodoló En El método epidemiológico en Salud Mental) pp. 271-292.
2. Del Barrio V (2009) Roots and evolution of DSM. Journal of History of Psychology. (Raíces y evolución del DSM. Revista de Historia de la Psicología) 30(2-3): 81-90.
3. Pacheco L, Padro D, Davila W, Alvarez S, Gomez P (2015) Historical notes on the current classifications of mental pathologies. North Mental Health (Apuntes históricos sobre las clasificaciones actuales de las patologías mentales. Norte de Salud Mental) 13(53): 83-92.
4. Novella EJ, Huertas R (2010) The Kraepelin-Bleuler-Schneider Syndrome and Modern Consciousness: An Approach to the History of Schizophrenia. Clinic and Health. (El Síndrome de Kraepelin-Bleuler-Schneider y la Conciencia Moderna: Una Aproximación a la Historia de la Esquizofrenia. Clínica y Salud) 21(3): 205-219.
5. Alvarez, JM, Colina F (2011) Historical origin of schizophrenia and history of subjectivity. (Origen histórico de la esquizofrenia e historia de la subjetividad). FRENIA 11(1): 7-26.
6. Clauss J, Danion-Grilliat A, Scarfone M, Hess V, Bonah C (2020) Reshaping the diagnostic borders of schizophrenia: the look of history of psychiatric practices. Schizophrenia Bulletin 46(1): 267.
7. Insel TR (2010) Rethinking schizophrenia. Nature 468: 187-192.
8. Koehler B (2017) APA: Drop the Stigmatizing Term “Schizophrenia”. Mad in America, Science, Psychiatry, and Social Justice.
9. Colodron A (2002) The schizophrenic condition. Madrid: Triacastela. (La condición esquizofrénica. Madrid: Triacastela).
10. Sass LA (1992) Madness and Modernism: Insanity in the Light of Modern Art, Literature and Thought. New York: Basic Books.
11. Casco M, Natera G, Herrejon ME (1987) The attitude towards mental illness, a review of the literature (La actitud hacia la enfermedad mental, una revisión de la bibliografía). Salud Mental 10(2): 41-53.
12. Thompson AH, Stuart H, Bland RC, Arboleda-Florez J, Warner R, et al. (2002) Attittudes about schizophrenia from the pilot site of the WPA worldwide campaign agaisnt the stigma of schizophrenia. Social Psychiatry and Psychiatric Epidemiology 37(10): 475-482.
13. Wahl OY, Harman CR (1989) Family views of stigma. Schizophrenia Bulletin 15(1): 131-139.
14. (2008) The International Society for the Psychological Treatments of the Schizophrenias and other Psychoses, ISPS. Changing the full name of ISPS 12(1): 1-16.
15. Esbec E, Echeburua E (2016) Violence and schizophrenia: a clinical-forensic analysis. Yearbook of Legal Psychology. (Violencia y esquizofrenia: un análisis clínico-forense. Anuario de Psicología Jurídica) 26(1): 70-79.
16. Kirkpatrick B (2009) The concept of schizophrenia. Rev Psiquiatr Sald Ment. (El concepto de esquizofrenia. Rev Psiquiatr Sald Ment) 2(3): 105-109.
17. (2009) Evolution of diagnostic criteria in the DSM and CIE systems. (s. f.). (Evolución de los criterios diagnósticos en los sistemas DSM y CIE. (s. f.)).

Abstract

Schizophrenia is one of the most controversial disorders for mental health researchers and all scientists around the world, because it is a disease of unknown etiology due to the complex interactions of genetics and environmental factors. According to Rodríguez-Pulido & González [1], schizophrenia historically has represented the paradigm of insanity, and innumerable theories have been developed to explain the origin of it.