I previously wrote of schizophrenia and how this term is often misunderstood within the public lexicon. There are points of conflict pertaining to the term and how this is used, or indeed even if this is useful within healthcare settings, and beyond. Developing an understanding regarding historical perspectives of schizophrenia may assist us in understanding both the utility and limitations of schizophrenia – as a label – within the 21st century.
It was Emil Kraepelin who, in 1897, separated psychosis into dementia praecox with a deteriorating course and manic depressive insanity with a recurrent course but usually better outcome. Eugen Bleuler, a Swiss psychiatrist, in 1908 introduced the world to the term ‘schizophrenia’ instead of dementia praecox. Bleuler used this terminology to describe what he saw as the ‘breaking up or splitting of psychic functioning’, employing the juxtaposition the Greek ‘schizen’ (‘to split’) and phren- (originally referred to as ‘diaphragm’ but amended to consider ‘soul, spirit, and mind’). The heritage of such terms persists within modern society with the erroneous concept of ‘split personality’ being employed to describe schizophrenia.
The legacy of Bleuler remained until Kurt Schneider, a German psychiatrist, refined the diagnostic criteria for a diagnosis of schizophrenia, these being later referred to as Schneiderian first-rank symptoms; with examples including delusional perception, auditory hallucinations, thought disturbance, and passivity. While the identification of schizophrenia was evolving and improving, there was little progress in terms of effective treatment options. At the time, potential interventions included an insulin shock therapy, introduced by Manfred Sakel; and a prefrontal leucotomy (today better known as a prefrontal lobotomy) for which António Egas Moniz was awarded the Nobel prize in 1949 (ten years after a near-fatal gunshot injury by an individual with a diagnosis of schizophrenia).
The serendipitous discovery of chlorpromazine, during anaesthesiology drug research, provided the first of our antipsychotic medications in the 1950s. This, a potent dopamine blocker, was a significant advance and the use of antipsychotics medications remain an important factor within the biopsychosocial treatment of those with a diagnosis of schizophrenia today. This medication, which paved the way of many subsequent medications, acts as a blockade of postsynaptic dopamine and reduces the hyperdopaminergic state within various dopaminergic pathways. However, it is critical to consider two points: firstly, hyperdopaminergic states have not been demonstrated in all cases of psychosis (some may argue only half of the cases were in this state). Secondly, a hyperdopaminergic state is likely to be a final common final pathway, as opposed to a causal mechanism within itself. Despite this, the use of antipsychotic medications holds utility for those being treated for psychosis and schizophrenia and is associated with decreased mortality rates.
The use of the term schizophrenia is not without its critics and various campaigns to abolish or amend the label have been initiated over the years; this is primarily based upon the negative stereotypes often associated with the label schizophrenia, along with the secondary discrimination. This notion has been supported, and also countered, by an argument suggesting a change of terminology should be more than mere semantics, and that addressing concerns regarding diagnostic criteria, revisions and adaptations of the concepts of illness and prognosis, as well as amendments to nosology, research, and education being critical. The evolution of language, from well-intended terms to how these are misused and misappropriated may result in some technological labels being employed as derogatory slurs; risking both societal and self-stigma.
A secondary concern regarding the use of the term schizophrenia pertains to how this is employed to define detachment from reality when recurrent or prolonged. The term schizophrenia, or the schizophrenia spectrum, holds utility in clinical practice and is broadly considered to reflect the heterogenous biopsychosocial nature of types of psychosis which are more likely to have poor outcomes. Indeed, restricting the term schizophrenia to cases where no causal mechanism is identified and where certain phenomenological features, such as disorders of self or where features associated with poor outcome (such as persistent primary negative symptoms or cognitive impairment are present) may be best. Utilising terminology such as psychosis secondary to specific contributory factors, where they have been identified in the person, may provide distinct benefits for the individuals using healthcare services, as well as healthcare providers. These contributory factors may include psychosis due to genetic factors (copy number variants or DNA deletion syndrome), secondary to substance misuse, or autoimmune conditions (or have an autoimmune component), as well as in response to psychosocial stressors such as the dual experience of racism and social inequality which appears to be the cause of high rates of psychosis in the UK Afro Caribbean community.
The use of the term schizophrenia may not capture the diversity of the syndromes which have historically been considered to sit beneath this label – indeed, this can impact upon the experience of the individual, the prognosis, and the treatment offered to the individual if the heterogenous nature of this diagnostic construct is ignored. Moreover, from a phenomenological perspective, the underlying experience of psychotic symptoms can vary between different conditions.
Clinical guidelines offer advice which doesn’t necessarily consider an individual’s personal circumstances to the degree that would be as helpful as it could be, so it is important in clinical care to add the individual factors back in. For example, and when considering the best suitable treatment options for an individual with psychosis, it is likely to be helpful to consider the underpinning contributory factors with regards the psychosis to be able to provide bespoke individualised treatment. Our clinical guidelines advocate a biopsychosocial approach, with signs and symptoms of psychosis being managed by use of antipsychotic medications combined with psychological interventions and social rehabilitation that enhances an individual’s ability to recover from or manage these symptoms in the short and longer-term. There are also needs to be a greater focus on addressing cognitive impairments such as making cognitive remediation more widely available.
However, the bespoke nature of one’s experiences and the contributory mechanisms of, require further exploration. There is some evidence that those with an autoimmune component to their psychosis are less likely to respond to antipsychotic medications; instead, requiring a variety of interventions [such as immunotherapy, infusion therapies and neuroimaging) which are almost entirely provided in environments detached from acute mental health services and are not discussed whatsoever within current clinical guidelines. Once more, the anachronistic concept of Cartesian dualism appears to contribute to more issues than it resolves. Moving forward, might it be that less frequent use of the term schizophrenia, with a renewed focus upon ‘psychosis secondary to autoimmune disorders or DNA deletion syndrome or substance misuse, etc.’ would result in a more comprehensive, less stigmatising experience for those whose require assistance from healthcare providers?
Joel Petch is an incoming senior lecturer at the Kent and Medway Medical School. Joel tweets @joelpetch
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