A grassroots campaign to drop the ‘schizophrenic’ label


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11:10 am - December 19th 2012

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by Claudia Tomlison

The term ‘schizophrenia’ is frequently misused in conversation to indicate a divided opinion, or erroneously taken to mean ‘split personality’. E.g.: ‘I feel schizophrenic on that particular point’.

Frequently also, in the public mind it is associated with violence, threat and danger when the evidence is to the contrary.

The experts agree that this diagnosis means different things for different people and that it is poorly understood.

An independent inquiry into the use of schizophrenia as a diagnostic label is under way to investigate its validity, usefulness, and impact on the lives of those to whom it is applied.

The inquiry published its preliminary findings last week, with responses from approximately 500 people, using a range of research methods. Most respondents report that the diagnosis in itself has damaged their lives, impacting relationships, friendships and employment opportunities.

Males of African and Caribbean descent are over-represented in those diagnosed with this condition with little will on the part of the current government to investigate this. The last Labour Governments acknowledged and addressed this issue, which has now been abandoned by the Coalition Government.

The Schizophrenia Commission, led by Professor Sir Robin Murray, made headlines earlier this year when it described the poor care and experience faced by people given this diagnosis.

The independent inquiry into the schizophrenia label goes further and challenges the use of this damaging label when the scientific basis is so poorly understood and controversial.

It seeks to work in partnership with people who experience very individual real life problems, to co-produce meaningful ways of describing their problems, whilst retaining their humanity. The final report from the inquiry will be published early in 2013.

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Reader comments


I must have walked into the wrong room. Where’s the article about a grassroots campaign to drop the word ‘schizophrenic’ as an insult? This article appears to be about an independent inquiry into the use of schizophrenia as a diagnostic label.

2. Chaise Guevara

“Frequently also, in the public mind it is associated with violence, threat and danger when the evidence is to the contrary.”

First full sentence of the source you use to support that: “It is now accepted that people with schizophrenia are significantly more likely to be violent than other members of the general population.”

Um… so your own source says that it is, in fact,associated with violence.

As to the meat of the article, I can understand that people object when it’s used as an insult. I’m not so sure it’s a problem for it to be used as a metaphor, which in my experience is most of the time when it’s used in a lay fashion. I suppose the usage does reinforce the misconception that it means “split personality”.

I dunno about the race thing. Is that a political issue or a scientific issue? In other words, do inequalities in our society mean black people are more likely to be tested, or are they just more likely to be sufferers?

Such a campaign would just be gay.

As someone with a bipolar condition I’m in two minds about this.

5. Chaise Guevara

@ GO

Might be worth renaming schizophrenia, like “spastic”, as it evidently does cause a lot of confusion. It doesn’t help that the name itself is factually wrong.

I dunno about the race thing. Is that a political issue or a scientific issue? In other words, do inequalities in our society mean black people are more likely to be tested, or are they just more likely to be sufferers?

Probably just more likely to be diagnosed as schizophrenic. It maps onto class too. As the OP suggests the term ‘schizophrenic’ covers a wide spectrum of disorders, some of which would be classed as ‘eccentricity’ in middle class black people.

When I was first diagnosed as bipolar it was following a manic episode virtually indistinguishable from schizophrenia.

7. Chaise Guevara

@ 6 Shatterface

I’m unconvinced. Do we have evidence of posh people being “diagnosed” as eccentric, then later being discovered to have schizophrenia?

I was thinking more along the lines of, black people still have poorer life outcomes, including being convicted of crime, and being convicted of crime might herald a psychiatric assessment. So it would still be a class thing, as the reason for higher crime rates among blacks is that they’re poorer on average.

But it also could just be about genetic predisposition (or both, obviously). The fact that there are racial differences on diagnosis rates is not in itself evidence of direct or indirect discrimination. And I’ll caution that, if the difference were the other way around, we’d currently be discussing whether black people are unfairly denied assessment.

Sorry, meant ‘some of which would be classed as ‘eccentricity’ in middle class white people’.

Incidentally, I think that ‘scizophrenia’ as a clinical diagnosis, and the public misunderstanding of ‘schizophrenia’ are two different things.

The public misunderstanding is of a Jekyll & Hyde-type ‘split personality’ and has more in common with bipolar conditions like bipolar II (hypomanic depression) and cyclothemia than to the more radical cognitive dysfunctions of people with a clinical diagnosis of scizophrenia or someone in a manic episode of bipolar I.

“…concerns about the nature of schizophrenia in other cultural groups and in societies in which industrialisation and economic productivity of the individual are not considered to be as crucial for an individual’s sense of belonging in a community.”

http://apt.rcpsych.org/content/7/4/283.full
and linked to in the OP

This seems to be suggesting that moving from a third world, tribal, agrarian society to an individualistic technological society could trigger mental illness. Other factors predisposing blacks to schizophrenia might be cannabis-use and the dysfunctional family structures found in afro-caribbean communities. More reseach needed, as they say.

I’ve changed the headline from ‘as an insult’ to a ‘label’ – which is more generic.
The point was to say people use the word schizophrenic as an insult when it can be a condition and sometimes the wrong label, but that didn’t come across in the original headline.

I have never ever heard “schizophrenic” being used as an insult.

Unlike, obviously, “spastic” once commonly was.

This seems to be suggesting that moving from a third world, tribal, agrarian society to an individualistic technological society could trigger mental illness

There was no schizophrenia in pre-idustrial Britain.

Plenty of ‘demonic possession’ though.

I have never ever heard “schizophrenic” being used as an insult.

Its usually abreviated to ‘schizo’ when used pejoratively..

@ 5 Chaise

Might be worth renaming schizophrenia, like “spastic”…

It didn’t work. Kids now use the word “Scoper” as an insult instead.

15. Chaise Guevara

@ 14

“It didn’t work. Kids now use the word “Scoper” as an insult instead.”

Oh, I know. I’m not talking about getting rid of an insulting term, I’m talking about removing honest confusion between schizophrenia and multiple personality disorder.

16. Man on Clapham Omnibus

What are we going to call a broken leg in future?

Oh who cares what words people use? The old left didn’t. They were better.

18. the a&e charge nurse

The term schizophrenia was coined in preference to its predecessor, ‘dementia praecox’ (precocious dementia)
http://en.wikipedia.org/wiki/Dementia_praecox

Is the contention of the OP that schizophrenia does not exist as a clinical entity, or it does exist, but schizophrenia is not the right word to describe it, or that it does exist, and schizophrenia is an acceptable term but the public need to be educated about it?

Misconceptions about multiple personalities may arise from the etymology of the word skhizein (split) and phren, alluding (in this instance) to heart/mind.

@ Chaise

Might be worth renaming schizophrenia, like “spastic”, as it evidently does cause a lot of confusion.

What word can you come up with that is going to put a positive spin on someone suffering from such horrific and terrifying symptoms of mental illness?

What word can you come up with that is going to put a positive spin on someone suffering from such horrific and terrifying symptoms of mental illness?

Neurodiversity.

@ 16. Man on Clapham Omnibus

What are we going to call a broken leg in future?

“A knackered leg” or “a fucked leg” obviously.

@OP, Claudia Tomlison: “Males of African and Caribbean descent are over-represented in those diagnosed with this condition with little will on the part of the current government to investigate this.”

How doctors diagnose mental illness is a medical thing. It is something that they should discuss as doctors, in public, of course. I hate to think that government has any role in identifying mental health problems.

The word “over-represented” has subjective meaning. Try “more present”: “Males of African and Caribbean descent are more present in those diagnosed with this condition…”

I’ll give some thoughts here, since I work in mental health.

Psychiatric diagnoses are essentially classification systems based on the kind of sets of problems that are being presented. It’s open to criticism because the diagnosis is usually based purely on what the patient tells the clinician, and how the patient is observed to behave. There’s no blood test for schizophrenia.

Though this is also true of quite a few non-psychiatric conditions. Say, idiopathic epilepsy. Or chronic fatigue syndrome.

Arguments have always raged about whether there are better ways of describing mental distress. For example, is it better to use a psychological formulation rather than a psychiatric diagnosis?

My own view is that when you use words to describe a problem, you can do it well or badly, helpfully or unhelpfully. Its level of usefulness may vary from person to person.

Also, people’s reactions to a psychiatric diagnosis can vary widely. I’ve worked with young people who I’m convinced are on the high-functioning end of the autistic spectrum, but they’re adamant that they don’t want to be diagnosed. So we don’t diagnose them, but just work on practical problems and solutions.

On the other hand, I have a good friend who recently told me about her overwhelming sense of relief at being diagnosed with obsessive-compulsive disorder. She described a sense of, “Okay, this is what is happening to me, and it explains why I’ve been having all these distressing thoughts.”

My view is a pragmatic one: Use diagnostic labels when it’s helpful to do so. Don’t use them when it’s not. And remember that even when you’ve diagnosed someone it’s a long way from describing all that they are and can be.

Don’t be dogmatic, is what I’m saying.

And on the subject of being dogmatic, I’m slightly concerned about something that calls itself an “inquiry”, but also calls itself a “grassroots campaign”. Are you sure you haven’t already made up your minds about what the conclusion of the inquiry will be?

24. Chaise Guevara

@ Pagar

“What word can you come up with that is going to put a positive spin on someone suffering from such horrific and terrifying symptoms of mental illness?”

It seems (genuinely, I’m not snarking at you) that we humans automatically assume that words are only changed for euphemistic purposes, because you’re the second person to think I want to change the spin despite me clearly saying we should maybe change it because it causes confusion.

The problem isn’t that “schizo” is used as an insult; the problem is that people think it means “multiple personality disorder”. As a&e explains above, this may be from the etymology, although I’ve always wondered how many people automatically translate from Greek (?) terms.

BTW, I have a track record of not being too bothered about “gay”, “mong” etc as insults, of defending terms like “an Englishman’s home is his castle”, and of laughing at people who complain about words like “manual” and “niggardly”, these last being mercifully rare (despite a US official losing his job over “niggardly”).

25. Chaise Guevara

@ 22 Charlieman

“The word “over-represented” has subjective meaning. Try “more present””

Or ambiguous meaning, at least… statistically higher than would be expected from base, or high enough to suggest some dark force at work? Cheers for raising this, it’s been bugging me lately and I keep letting it slide.

While I’m at it, I take exception to “misused” in the first sentence of the OP. From a linguistic standpoint, I don’t think that colloquial uses of terms are wrong, even if they substantially differ from the technical. So I’ll wince but put up with it when people use “quantum leap” to suggest that the leap is large.

Sorry Sunny but this is, as my old Mam used to say, “a load of nowt about nowt”.

27. Chaise Guevara

@ 23 Zarathustra

“And on the subject of being dogmatic, I’m slightly concerned about something that calls itself an “inquiry”, but also calls itself a “grassroots campaign”. Are you sure you haven’t already made up your minds about what the conclusion of the inquiry will be?”

Quite definitely, based on the OP. Also, I think “grassroots” is one of those words that it just feels really good to say.

Having browsed the site, I’m rather concerned about selection bias. They have a page inviting people to complete a survey and submit testimonials.

http://www.schizophreniainquiry.org/get-involved

Okay, anyone can fill in the survey, but it’s on a site where the authors have clearly nailed their colours to the mast in terms of what they think of the schizophrenia label.

People who think it’s a load of rot, put together a site saying they think it’s a load of rot, and ask people to complete a survey. Funnily enough, they get a set of answers saying it’s a load of rot.

Doesn’t strike me as very rigorous, to say the least.

@28. Zarathustra: “Having browsed the site, I’m rather concerned about selection bias.”

“Rather concerned?” If you are unable to determine a conclusion, that’s fine. But if you use a euphemism, everything that you say following it has to be really, really neutral.

Zarathustra: “Doesn’t strike me as very rigorous, to say the least.”

That is much better.

30. Claudia Tomlinson

Thank you for taking the time to read my post. Word limits can mean there is not always the space to fully discuss complex issues such as this. This inquiry is a starting point, and is iterative so early learning indicates what might be helpful. This work is also new, and being undertaken with no resources by people who are committed to improving the experience of those receiving this diagnosis, about 1 in every 100 of the UK population.
In terms of the research on the association with violence, it can be difficult to interpret the key messages from the study referenced, however it is important to read the whole study rather than just the opening sentence. This quote from the study is a good summary of the picture:
“Most studies confirm the association between violence and schizophrenia. Recent good evidence supports a small but independent association. Comorbid substance abuse considerably increases this risk. The proportion of violent crime in society attributable to schizophrenia consistently falls below 10%”
There is an association, but factors include poor care, support, and drug use. The actual incidence is much lower than the public supposes, which is the key point.
If we look at the example of amendment to another diagnosis, Manic Depression, which was discontinued and more usefully described as Bipolar Disorder. It is also less stigmatising.
This inquiry is also generated out of a groundswell of concern about the use of schizophrenia as a label, and gives voice to those who would not otherwise be able to contribute their views so an open, qualitative inquiry suits the situation of the participants.
Thanks again for your interest and re-tweets.

@30. Claudia Tomlinson: “Thank you for taking the time to read my post. Word limits can mean there is not always the space to fully discuss complex issues such as this.”

Thanks to people like Sunny, you Claudia, have many opportunities to expound you thoughts. You should not refrain from using them.

Hi Claudia

Can you tell us a little about how research participants were recruited? What kind of steps were taken to avoid selection bias?

I’m not disputing the need to ask the questions that are being looked into, but I’m wondering about how the sample was generated.

33. the a&e charge nurse

The term (schizophrenia) is 100 years old – good article here saying;
“It (schizophrenia) has no scientific basis, it is harmful, and it makes stigma worse. In addition to this, it is a barrier to recovery, and it is an obstruction to the possibility of finding meaning in psychosis. It invokes powerlessness, and disregards personal contexts of trauma and abuse”.
http://www.criticalpsychiatry.co.uk/index.php?option=com_content&view=article&id=46:the-case-against-schizophrenia&catid=35:documents&Itemid=56

Additionally, “there is no evidence that there are any specific biological treatments for schizophrenia. Although antipsychotic drugs are sometimes claimed to reverse a biochemical imbalance, no such imbalance has been demonstrated. The drugs are more likely to work through their general suppressant effects, which they exert in anyone who takes them and not just in people diagnosed with schizophrenia” – in other words those on antipsychotics not only lose interest in their symptoms but to a certain extent in life.

For those with predominantly ‘negative’ symptoms the effects of antipsychotics are even more questionable. Negative symptoms represent a withdrawal or lack of function, for example, at some point a % of people with schizophrenia appear emotionless, flat and apathetic.

34. So Much for Subtlety

30. Claudia Tomlinson

This work is also new, and being undertaken with no resources by people who are committed to improving the experience of those receiving this diagnosis, about 1 in every 100 of the UK population.

Actually most of what you have to say seems to have nothing to do with the experience of those with this disease and is more about bullying the rest of us. Odd that. Just how will giving this disease a different name have any impact whatsoever on the people with this disease (or more likely diseases)?

1 in every 100 of the population have this disease? Well your source says The proportion of violent crime in society attributable to schizophrenia consistently falls below 10%. That looks like people with this disease are grossly more likely to commit a violent crime.

There is an association, but factors include poor care, support, and drug use.

None of the studies mention poor care or support from what I can see:

Unselected birth cohort studies

Hodgins (1992), in a 30-year follow-up of an unselected Swedish birth cohort, found that compared with those with no mental disorder, males with major mental disorder had a 4-fold and women a 27.5-fold increased risk of violent offences. No separate data were provided for schizophrenia. A later study using the same methodology revealed similar findings (Hodgins et al, 1996).

The first cohort study to demonstrate the quantitative risk of violent behaviour for specific psychotic categories followed an unselected birth cohort of 12 058 individuals prospectively for 26 years (Tiihonen et al, 1997). The risk of violent offences among males with schizophrenia was 7-fold higher than controls without mental disorder.

Brennan et al (2000) traced all arrests for violence and hospitalisations for mental illness in a birth cohort followed to age 44 years. Schizophrenia was the only major mental disorder associated with increased risk of violent crime in both males and females, adjusting for socio-economic status, marital status and substance abuse.

Arseneault et al (2000) studied the past-year prevalence of violence in 961 young adults who constituted 94% of a total city birth cohort. Three Axis I disorders were uniquely associated with violence after controlling for demographic risk factors and all other comorbid disorders: alcohol dependence, marijuana dependence and schizophrenic spectrum disorder.

It looks like people with this disease pose a significant threat to the well being of the rest of British society. Especially if they smoke marijuana. So no problems legalising that then.

The actual incidence is much lower than the public supposes, which is the key point.

Instead of being disastrous it is merely serious?

If we look at the example of amendment to another diagnosis, Manic Depression, which was discontinued and more usefully described as Bipolar Disorder. It is also less stigmatising.

How was it more useful? They simply bullied the rest of us into changing the way we referred to this poorly understood disease. It would usually take a few weeks for people to start using the new term just as they used the old term. No doubt we will be bullied into an even newer term now. School children regularly call each other “Special Needs” these days, and more so “Gay”. You can’t remove the stigma from what will always be stigmatised. Nor should you. Mental health is not about bullying the rest of us. It should be about treating patients.

This inquiry is also generated out of a groundswell of concern about the use of schizophrenia as a label

A groundswell consisting of a tiny number of activists and their hangers on I expect. I see no demand in the community to change the language.

35. So Much for Subtlety

Males of African and Caribbean descent are over-represented in those diagnosed with this condition with little will on the part of the current government to investigate this. The last Labour Governments acknowledged and addressed this issue, which has now been abandoned by the Coalition Government.

I assume this is just a little misdirection to suggest that the industry is racist. In reality schizophrenia has been linked to several possible causal factors. One of which is marijuana use. Which tends to be higher in the Afro-Caribbean community. Another is a lack of Vitamin D. Which obviously, in the UK, is a bigger problem for the African and Afro-Caribbean communities. It also tends to be linked in every society all over the world to immigration. It may be that it has a infectious cause. Perhaps some disease or parasite that locals have built up immunity to but which immigrants have not.

All plausible answers that do not need anyone to leap to the conclusion that the whole industry is racist. But it is interesting how this seems to imply the science is irrelevant and the politics is what matters.

@35. So Much for Subtlety: “I assume this is just a little misdirection to suggest that the industry is racist.”

What/which industry?

37. Chaise Guevara

@ 29 Charlieman

““Rather concerned?” If you are unable to determine a conclusion, that’s fine. But if you use a euphemism, everything that you say following it has to be really, really neutral.”

I agree about hands-off language. I’d use the term “weasel words” here rather than “euphemism”. But it’s a standard turn of phrase, and Zarathustra is absolutely right. Based on what he/she has seen, the idea of an interested site taking pop polls is not encouraging.

I’ll also point out that, from what I’ve seen, Zarathustra has made more effort than the rest of us to determine what’s what.

If we look at the example of amendment to another diagnosis, Manic Depression, which was discontinued and more usefully described as Bipolar Disorder. It is also less stigmatising.

I’m not sure changing the label has made any appreciable difference to my life. ‘Biploar’ makes it sound like I’m miserable 50% of the time and happy the other 50% and everything balances out.

Periods of depression last way longer than manic or hypomanic episodes, and the latter more resemble a cocaine high than ‘happiness’, being – at best – characterised by irritability and restlessness rather than contentment.

Oh dear, where to start with this one?

Complex is a bit of understatement when it come to describing the issues that are being touched on here.

Yes, there are long-standing questions about the diagnostic validity of schizophrenia, and some other common diagnoses even though things have improved somewhat since the 1970s – before that a diagnosis of schizophrenia often meant ‘we’re pretty sure they’re nut but have no idea why’.

Even today, the diagnostic criteria are so broad and varied that its quite common to find patients with the same diagnosis – schizophrenia – who lack any symptoms in common and that does raise serious questions.

To that already complex debate we need to add the parallel debate about the possibly excessive power and influence of a number of large and highly profitable American psychiatric practices and the pharmaceutical industry in shaping diagnostic criteria – just Google “DSM V” and you’ll see how long that’s been raging.

Then there’s the question of whether a higher prevalence of diagnoses in a particular minority community indicates that that community is, for whatever reason, more susceptible to a particular condition or whether the differential is down to possibly faulty assumptions about race and ethnicity, gender, etc. This is, again, a long-standing and complex issue, and in fact it is still, even today, the case that women are around twice as likely to be referred for Electroconvulsive Therapy than men for reason which are entirely unclear.

And on top of that we have the problem of public and media attitudes and the rather ignorant misuse of diagnostic and other labels. ‘Schizo’ is still kicking around as an insult, although it seems to be rather less common that it used to be, but there is still the issue of the media having unilaterally redefined the diagnostic boundaries for paedophilia from puberty to the legal age of consent.

Worse still are some of the common examples of colloquial ignorance. Only the other day there was a prime example on ITV’s ‘This Morning’ where they we doing a slot with a mentallist (stage magician) only for Ruth Langsford to giggle and announce that she finds that word funny because its makes her think of mental illness. Ha ha fucking ha.

So, yes, lots to tackle but then I’m really not sure that this ‘independent inquiry’ will add much to the debate because it really doesn’t look independent at all. In fact is has all the appearances of activist-driven ‘inquiry’ which will largely serve to promote a competing set of narratives many of which are equally problematic and lacking in sound evidential foundations.

Just looking at the list of supporters there is at least one anti-pharma group in there for starters and there’s also the Alliance for Counselling and Psychotherapy, which was set up in order to oppose moves to improve professional regulation and which draws much of its support from people operating at the quackery end of the field.

The wider issue in all this is that most of the public have no idea of just how little of what passes for standard psychiatric practice has any kind of basis in reliable evidence and the problem is no less marked in respect of many talking therapies than is it is relation to the use of drug treatments in psychiatric settings. All the talking of working with service users’ own narratives sounds wonderful in principle but in practice what it can mean – if they’re unlucky – is nothing more than exposing them to whatever their counsellor or therapist might happen to believe in which, in some cases, will amount to not much more than a whole bunch of bullshit and voodoo.

There is a desperate need to put the entire field of psychiatric practice on to much more solid scientific and evidence-based foundations and, sadly, what I can’t see this particular inquiry doing is contributing much to that at all.

40. the a&e charge nurse

[37] ‘the idea of an interested site taking pop polls is not encouraging’ – I think this debate goes far beyond ‘pop polls’ and links into a burgeoning discourse about the meaning of the term, schizophrenia, found in other forums (see link @33)

For somebody to be saddled with a medical diagnosis that has such a profound affect on subsequent life chances I think there is a professional obligation to be pretty certain about the phenomena that is being categorised in this way – at present psychiatrists are not even close to such certainty, let alone possessing much in the way of treatment.

A lot of people vilified RD Laing but for he me he was the first person to really switch a light on about the unhealthy power dynamics between psychiatric patients, and the psychiatric system (including the language that became prevalent in this sphere) – this debate is part of that ongoing discourse and Claudia Tomlinson, and others are quite right to question the validity of the term.

41. the a&e charge nurse

[39] ‘before that a diagnosis of schizophrenia often meant ‘we’re pretty sure they’re nut but have no idea why’ – so what has changed?

What is the single most compelling piece of evidence for schizophrenia that you aware of? (leaving aside the multitude of competing hypothesis)

For example, commentators like Brian Daniels (National spokesperson, Citizens Commission on Human Rights, UK) have said “After a century of research, there is a complete absence of objective proof that ‘schizophrenia’ exists as a physical brain abnormality”.

And ….. psychiatry completely ignores this weight of scientific evidence, preferring to assign all blame to illnesses and supposed ‘chemical imbalances’ in the brain that have never been proven to exist, and limits all practice to brutal treatments that have done nothing but permanently damage the brain and the individual. Rather than returning the patient to good health, the drugs used to treat ‘schizophrenia’ cause damage to the body’s nervous system and result in permanent impairment and even death. Completely ignorant of what they are dealing with, psychiatrists simply prefer the expedient approach of ‘throwing a hand grenade into a switchboard to fix it.’

You call for a scientific basis, so presumably if there is no scientific basis for the term schizophrenia then presumably like Claudia Tomlinson and others you object to its use?

42. Chaise Guevara

@ a&e

You’re effectively calling for an end to pretty much all psychiatric diagnosis and, presumably, treatment. Psychiatric definitions are extremely debateable, and the DSM is frequently criticised. The fact that we don’t live in a perfect world doesn’t mean we should make this world worse.

A&E

You are aware, of course, that the so-called Citizen’s Commission on Human Rights is a primarily front organisation for Scientology, which has a long standing antipathy towards psychiatry.

As regards schizophrenia, I’m inclined to take the same view of my old clinical psych lecturer, which is that we would start to make some progress if only we were to think in terms of there being schizophrenias (plural) – it is not a singular condition but a rather a complex and diverse class of conditions much as cancer is not a singular condition.

Ad for there being a most compelling piece of evidence for schizophrenia, it depends what kind of evidence you’re looking for. if it biochemical or neurological evidence you’re after then you’ll really struggle to find anything particularly compelling. It, like most other psychiatric conditions, does not have an obvious or uniform organic cause which mean that, inevitably, one will run into the mind-body problem.

That is why, of course, the vast majority of psychiatric conditions are defined in terms of clusters of symptomatic behaviours even thought that creates difficulties because defining what is abnormal necessarily requires one to take a view on what you consider to be normal and normative arguments are necessarily heavily influenced by sociocultural factors that may, themselves, be somewhat questionable.

That, as I’m sure you are aware, just from your having mentioned Laing, is the essence of the anti-psychiatry movements critique – and I will happily admit to having a soft-spot for dear old RD who brought a refreshing no bullshit approach to the field.

These are inherently difficult questions. One of the more common criticisms of DSM is that it too often medicalises what should otherwise be regarded as normal behaviours and yet the very essence of psychiatric medicine is that even what we consider to be normal behaviours can become problematic for some individuals in some circumstances.

One of the more heated debates about DSM related to the inclusion of grieving in the new diagnostic criteria for depression because grief is a perfectly natural human reaction to the loss of loved one, at least until it reaches a point at which it becomes problematic for the person experiencing those feelings because, rationally, they reach a point where they consider that its time for them to move on and get on with life only for them to also feel that continued feelings of grief and loss present a barrier that is holding them back for what they want to do with their life.

There is a significant subjective element to many diagnoses which makes it difficult to pin down clear, objective, diagnostic criteria but nevertheless that doesn’t mean that those criteria lack any validity only, as Zarathustra correctly points out, that they need to be used judiciously, at least until we can refine our understanding of such conditions.

What is needed, more urgently, is a much stronger focus on evaluating treatment options in a more rigorous manner, but that’s a huge debate in itself and one that stretches far beyond the use of pharmaceuticals in psychiatric practice.

44. the a&e charge nurse

[42] “The fact that we don’t live in a perfect world doesn’t mean we should make this world worse” – that’s all people with a diagnosis of schizophrena are asking for; respite from a label with almost universal negative connotations despite the fact it has no evidential basis (although lots of hypothesis).

[43] “As regards schizophrenia, I’m inclined to take the same view of my old clinical psych lecturer, which is that we would start to make some progress if only we were to think in terms of there being schizophrenias (plural)” – there already are – none are especially helpful for the recipient.
http://www.news-medical.net/health/Schizophrenia-Diagnosis.aspx

The OP is calling for a shift in emphasis – away from a system of classification that despite 100 years of trying still cannot define the phenomena before it, toward one that at least puts the needs of the patient at the heart of services.

Once upon a time there was a condition known as general paralysis of the insane which in time had a proven biological basis (tertiary syphilis) – some argue a similar pattern will play out with schizophrenia – well maybe it will, and maybe it won’t but until it does (if it does) I think it is not unreasonable to ask for a little more humility by health professionals when so much clinical uncertainty exists.

Just a few points, as I’ve come to this debate rather late, but we do need to clarify some misconceptions about the term ‘schizophrenia’.

There is a strong correlation between psychosis (a symptom which might indicate schizophrenia) and marijuana use. The problem is that marijuana has a similar affect to anti-psychotic medication, ie it can alleviate symptoms, so those suffering psychosis effectively self-medicate. Paradoxically, marijuana use is also known to cause psychosis and/or paranoia, so it’s difficult to ascertain which might be cause and effect at an individual level.

People who suffer from or have a diagnosis of schizophrenia are at no more risk of being violent than the normal population, however, there is a higher risk of substance/alcohol use within that population which does increase the risk of violence, but this is also the case for those without a diagnosis. but who do abuse drink/illegal substances.

Is there a physical cause or is it ‘faulty cognitive processes’,this is still the subject of debate, whatever it is, we know that it results in distorted sensory perception. If it’s physical, we would expect an organic/chemical ‘cure/intervention’, if not, we are in the area of psychotherapy and the opponents of psychiatry such as Thomas Szasz, although a&e@40 quotes Laing, and I agree that big pharma have too much influence on the diagnostic criteria.

As far as the label ‘schizophrenia’ goes, it certainly replaced the notion of demonic possession, but is no less stigmatizing and, unfortunately, it now seems to be confused with the term ‘psychopath’, which is something entirely different.

There are two trains of thought about diagnosis, one is that it can be stigmatizing (certainly in the case of schizophrenia) or it can be liberating in that the person has something concrete to explain the mental distress. Either way, we certainly need more research, but we need to also address the failure of the mental health services to adequately find outlets for dispelling the myths about mental illness, because until we have a society which continues to negatively react to mental illness, those who suffer mental distress will either attempt to hide the symptoms, isolate themselves or self-medicate with alcohol/drugs,

46. Chaise Guevara

@ 44 a&e

“that’s all people with a diagnosis of schizophrena are asking for; respite from a label with almost universal negative connotations despite the fact it has no evidential basis (although lots of hypothesis).”

I wasn’t talking about that, I was talking about your invocation of the perfection fallacy a la diagnosing mental illnesses. But, as I pointed out above, the link in the OP used to back up the idea that schizophrenia is not associated with violence in fact states that it is associated with violence. I’d call that negative.

More generally, of bloody course it has negative effects. That’s why people seek treatment. Fancy hearing voices in your head?

The way I see it, two problems with the term:

1) People mix it up with multiple personality disorder.
2) People use it as, effectively, an insult: “He went schizo on me!”

The first is the reason I agree we should maybe change the term. The second, not so much: after we replaced “cripple” with “handicap[ped]“, the latter became offensive and had to be replaced with “disabled”. I’ve since seen people claiming that “disabled” is offensive and should be replaced with “differently abled”, because apparently we’re not safe till a term is euphemistic enough to count as a straight-out lie. And so on until the mountains fall and the seas run dry.

About the only way you could get around this is by using a long word that is hard to contract.

47. Chaise Guevara

@ 45 steveb

“People who suffer from or have a diagnosis of schizophrenia are at no more risk of being violent than the normal population, however, there is a higher risk of substance/alcohol use within that population which does increase the risk of violence, but this is also the case for those without a diagnosis. but who do abuse drink/illegal substances.”

Ah. That’s interesting and could very well be an explanation. Have you got a source?

“Is there a physical cause or is it ‘faulty cognitive processes’,this is still the subject of debate”

Isn’t that a debate over a flawed distinction anyway? Unless we’re gonna get religious, brains and minds are the same thing. As far as I can tell, the difference between neurology and psychiatry is just that the former describes stuff where we have a better handle on the physical causes.

47 Chaise

An interesting article in Guardian online – ‘Substance abuse, not mental illness, causes violent crime’ Guardian, 6th September, 2010. I have taken my reference from research done for the Department of Health but can’t identify it on the internet, next time I’m in the office I’ll attempt to locate the title of the document.

Although, as you point-out, the brain is physiological in the same way as the body, there is a distinction between ‘damaged/malfunctioning’ physiology and normal physiology but with unusual learnt/experiential ways of processing information, where the most appropriate treatments would be talking/psychotherapies, post traumatic stress disorder is one example.

The real problem for people suffering a mental disorder is societal attitudes, those attitudes have also been internalized by those who suffer, which does lead to attempts to self-medicate or withdraw, which in itself increases mental stress. Unfortunately, self-medicating with illegal substances or alcohol increases the risk of violence for all, note the number of violent incidents in city/town centres at the week-end, this is labelled ‘drunken/drug fueled behaviour’, but not when the person also suffers from a mental illness.

Rather than worry about isolated words and language, it would be better to do something about the actual problems that so many of the disabled and those withmental health problems are facing now.

The real problems are welfare cuts and the dismantling of the benefit system coupled with the aggressive enforcement of debts by state bureaucracies using private bailiffs (see the debate in the House of Lords and the amendment moved by Lady Meacher and the Bishop of Lichfield on 18 December 2012 regarding the Crime and Courts Bill) not calling someone “schizophrenic”.

In practice it is not the choice of any particular words for mental or physical illness which is harming people throughout Britain today as we approach 2013, but the fact that their benefits are being sanctioned or reduced under the Welfare Reform Act 2012, the fact that they will be being hit by housing benefit caps rather than rent caps and that legal aid and advice services for the most vulnerable are being slashed. From April 1st 2013 many people will lose help with their council tax with the abolition of council tax benefit which will heap yet further debtand misery on the vulnerable. Rather than worry about words like “schizophrenic” the Left and progressives ought to be actually looking at the words contained in the anti-welfare legislation which actually impacts upon the lives of the poorest and most vulnerable. As Dickens warned in a Christmas Carol in 1843, want and ignorance about the actual lives are the things to be feared in British society today. Merry Christmas everyone.

50. Robin Levett

@steveb #45:

People who suffer from or have a diagnosis of schizophrenia are at no more risk of being violent than the normal population, however, there is a higher risk of substance/alcohol use within that population which does increase the risk of violence, but this is also the case for those without a diagnosis. but who do abuse drink/illegal substances

How does that match up with the studies referred to in the literature review referred to in the OP – which finds that:

It has been demonstrated repeatedly that schizophrenia with comorbid substance abuse increases the risk of violence considerably compared with schizophrenia without comorbidity (Swanson et al, 1990; Cuffel et al, 1994; Tiihonen et al, 1997; Wallace et al, 1998). It is important to note that because there is an increase in violence risk in those without comorbidity, substance abuse merely increases the level of risk rather than causing it (Arsenault et al, 2000; Brennan et al, 2000). Hence, the risk from substance abuse appears to be additive.

49

Although I agree with the points you make about funding, you are quite wrong about the impact of receiving a diagnosis of ‘schizophrenia’, because few people really understand the illness.

50

You are quoting quite old research, and as I have outlined @45, it is now known that a large number of people with schizophrenia had turned to substance misuse to treat the underlying disorder before receiving a diagnosis. All substance misuse is going to increase the risk of violence across the whole population and I agree, this is an additive risk.

The biggest risk to people with mental illness is societal attitudes, which can be hard to change, as your recent posts about mental illness highlight.

52. Derek Hattons Tailor

Yeah because the label is the real problem isn’t it ?
And changing it always makes the problem better. Obviously the general public don’t have a clinicians understanding of mental illness – why would they ?

For what it’s worth, research indicates

In cognitive terms, Schizophrenia is a breakdown of some of the filtering that separates concious from unconscious thought

It has neural correlates. Schizophrenics experiencing auditory hallucination have the same localised neural activity you would expect to see in someone hearing real voices

It may have a physical cause, the endocrine system is implicated (Schizophrenics are more likely to be diabetic) but the causation, if there is one, is extremely complex and poorly understood.

It does not have a social cause as the rate of incidence in the population is stable and does not increase, as might be expected, in times of increased societal stress.

Substance abuse might be attempts at self medication as alcohol in particular reduces some of the symptoms – which might or might not be the cause of increased diabetes

52

Are you replying to me, if so, I didn’t suggest changing the label it’s the changing of attitudes which would make the biggest impact.

And thanks for your lecture on schizophrenia, and you forgot to add that most with the diagnosis end up with heart disease, respiratory conditions, high blood pressure, high cholesterol levels and a substantially reduced life-expectancy due to physical illness.

As for your comment about a social cause, well done, you are ahead of the mental health services, but what is definitely known is that societal attitudes escalate the problems from discrimination by employers and landlords to neighbours of people with the diagnosis. This leads to isolation, physical neglect, increases in drug/alcohol/smoking and adding depression to the mix.

54. Derek Hattons Tailor

@ 53 No I wasn’t replying to you, but thanks for the sarcastic response anyway. I mean it’s not like “the mental health services” ever get anything wrong is it.
(asylums, ECT, “care” in the community et al)
What you are talking about is discrimination against people with a diagnosis. That is nothing to do with the cause(s) of the disorder. Please spare me a Laing inspired lecture though, its so 1970s

54

I outlined how discimination escalated the problem, and how can you say, on one hand, that asylums were wrong and on the other, so is community care. I’m not so sure that ECT is wrong, I certainly know of quite a few people that the treatment has changed their life in a positive way.

56. Robin Levett

@steveb #51:

You are quoting quite old research

Well, actually, the OP is quoting the research – or rather misquoting it.

The biggest risk to people with mental illness is societal attitudes, which can be hard to change, as your recent posts about mental illness highlight.

Really? Explain, please.

57. the a&e charge nurse

Steve B said @51 “The biggest risk to people with mental illness is societal attitudes, which can be hard to change, as your recent posts about mental illness highlight”.

Robin L @56 responded, “Really? Explain, please.”

This interface has been discussed in a number of papers – bottom line, negative public attitudes are additional burden for certain vulnerable groups – see;
Alonso J et al (2009) Perceived stigma among individuals with common mental disorders. Journal of Affective Disorders; 118: 180-186.
Angermeyer MC, Matschinger H (2005) The stigma of mental illness in Germany: A trend analysis. International Journal of Social Psychiatry; 51: 276-284.
Blenkiron P (2009) Psychiatry in the Media. London: Royal College of Psychiatrists.
Bos AE et al (2009) Mental illness stigma and disclosure: consequences of coming out of the closet. Issues in Mental Health Nursing; 30: 509-513.
Corrigan P (2004) How stigma interferes with mental health care. The American Psychologist; 59: 7, 614-625.
Corrigan P et al (2001) Prejudice, social distance, and familiarity with mental illness. Schizophrenia Bulletin; 27: 219-226.
Crisp AH et al (2005) Stigmatization of people with mental illnesses: a follow-up study within the Changing Minds campaign of the Royal College of Psychiatrists. World Psychiatry; 4: 106-113.
Crisp AH et al (2000) Stigmatisation of people with mental illnesses. The British Journal of Psychiatry; 177: 4-7.
Department of Health (undated) Stigma.
Department of Health (2004) Shift…Shifting Attitudes to Mental Illness.
Department of Health (1999) National Service Framework for Mental Health: Modern Standards and Service Models. London: HMSO.
Dinos S et al (2004) Stigma: the feelings and experiences of 46 people with mental illness. British Journal of Psychiatry; 184: 176-181.
International Council of Nurses (2008) Mental Health: ICN Position. Geneva: ICN.
Livingston JD, Boyd J (2010) Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Social Science and Medicine; 7: 2150-2161.
Lyons C et al (2009) A decade of stigma and discrimination in mental health: plus ça change, plus c’est la même chose (the more things change, the more they stay the same). Journal of Psychiatric and Mental Health Nursing; 16: 501-507.
Queensland Alliance for Mental Health (2010) From Discrimination to Social Inclusion. A Review of the Literature on Anti Stigma Initiatives in Mental Health.
Sato M (2006) Renaming schizophrenia: a Japanese perspective. World Psychiatry; 5: 53-55.
Social Exclusion Unit (2004) Mental Health and Social Exclusion: Social Exclusion Unit Report.
Thornicroft G (2006) Actions Speak Louder… Tackling Discrimination Against People with Mental Illness. London: Mental Health Foundation.

The Sato paper (Japan) deals specifically with the re-naming schizophrenia issue – from 2002 they have preferred the term “Togo Shitcho Sho”, or “integration disorder”.

58. Robin Levett

@a&ecn #57:

It was the reference to my attitudes as demonstrated by my recent posts that I was asking steveb to explain.

58

Your recent posts show a disregard to recent research, and an insistence even rigidity about voicing the stereotypal attitude to people with schizophrenia. I wonder if you looked at my reference @48.

Certainly, pleading mental illness when defending clients on various charges in a criminal court may appear expedient, but this just continues to reinforce attitudes when the press take the term ‘mental illness’ and run with it.

@48, I also make the point that if people with schizophrenia commit offences under the influence of alcohol/drugs, the mental illness is cited as the cause otherwise those who have no diagnosis, the behaviour is attributed to drink/drug fueled behaviour.

60. Robin Levett

@steveb #59:

Your recent posts show a disregard to recent research, and an insistence even rigidity about voicing the stereotypal attitude to people with schizophrenia. I wonder if you looked at my reference @48

No; you haven’t yet produced the reference – or are you suggesting that the Grauniad is sufficiently authoritative to stand as research itself.

My recent posts on the murder/suicide thread were based on 2009 research – you provided no reference to any research. The literature review that the OP itself refers to was conducted in 2001, and rthe oldest papers in that review are from 1984; most of the papers are late-1990s. If you have any recent research not referred to in that review, then refer me to it. If not, then stop accusing me of ignoring the research.

What is the “stereotypical” attitude to schizophrenics that I am rigidly voicing? The only reference I have made in this thread is to the review that the original poster herself chose to treat as authoritative, while apparently, if you are correct, misunderstanding it completely and ignoring recent research.

61. Robin Levett

@steveb:

One other point; even taking the Grauniad report at face-value, it doesn’t necessarily mean what you say it does. The review article in the OP states that:

It thus fails to take into account other risk factors or confounding factors that may be operating in the association between a particular risk factor and disease. As we have seen previously, for example, comorbidity substantially increases the risk of violence in schizophrenia and it is thus possible that if substance abuse was to be eliminated from the population, the contribution to violence made by schizophrenia alone would be much less.

But the author of the report cited in the Grauniad is quoted as saying:

Research has shown that around 20% of people with bipolar disorder abuse alcohol and drugs compared with about 2% of the general population. Dr Fazel said that one reason for this might be that substance abuse was “genetically programmed” into patients.

“We are looking at two reasons why this figure is higher. One is whether patients attempt to self-medicate with substance abuse. The other is that there is a possibility of genetic predisposition towards substance abuse given that schizophrenia and bipolar disorder both have an element of genetic predisposition.”

You do the math…

60/61

The fact, or otherwise, that there may be a predisposition to substance abuse does not change the fact that substance abuse increases the risk of violence whether or not the person has a mental illness, a predisposition to substance abuse or neither of the two.

63. Robin Levett

@steveb #62:

The fact, or otherwise, that there may be a predisposition to substance abuse does not change the fact that substance abuse increases the risk of violence whether or not the person has a mental illness, a predisposition to substance abuse or neither of the two.

That’s not in issue in the slightest. Nor is it relevant to the fact that schizophrenia increases the risk of violence – which even the Grauniad referenced paper seems to agree. Do you have a copy of the paper itself? It’s not unknown for the press-release to bear little relation to the actual findings of the paper, so I’d prefer to take my science from the source, rather than as interpreted by a journalist.

63

I don’t have a copy of the original research because I am taking my reference from research undertaken on behalf of the Dept. of Health, unfortunately I can’t find the document on the internet but I did state @48 that I would attempt to find the title of the document.

You are still failing to acknowledge that substance abuse creates a higher risk of violence, it doesn’t matter whether a person has a mental illness or not and I agree that people with schizophrenia are more likely to abuse substances for all the reasons I have stated in preceding posts. It’s a classic example of correlation but not causality.

65. Robin Levett

@steveb #64:

You are still failing to acknowledge that substance abuse creates a higher risk of violence

To the contray – I explicitly acknowledged it in the post to which you are replying.

Here’s a blog post by me on the Schizophrenia Inquiry, outlining my own thoughts.

http://theworldofmentalists.com/2012/12/23/will-the-schizophrenia-inquiry-achieve-its-aims/


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