Download At Issue: Impact of the Term Schizophrenia on the Culture of

Impact of the Term Schizophrenia on the
Culture of Ideograph:
The Japanese Experience
by Yoshiharu Kim and Qerman E. Berrios
The At Issue section of the Schizophrenia Bulletin contains viewpoints and arguments on controversial issues.
Articles published in this section may not meet the strict
editorial and scientific standards that are applied to
major articles in the Bulletin. In addition, the viewpoints
expressed in the following article do not necessarily represent those of the staff or the Editorial Advisory Board of
the Bulletin—The Editors.
tries where the Chinese writing system is used, however,
ignorance of Greek is not protective, as "schizophrenia" is
written with the ideographs for "split mind," which
directly express a meaning to laypeople.
The Japanese Experience
The Japanese translation of "schizophrenia" is seishinbunretsu-byo ("mind-split-disease"; figure 1). This translation has been made from the Greek roots schizein,
"splitting"; phren, "a breath and soul"; and the suffix -ia,
which indicates a disease.
Abstract
The ideographic Chinese writing system (in use in
Asian countries that account for about a quarter of the
world's population) directly expresses the meaning of
schizophrenia as "the disease of disorganized mind."
The term directly challenges a deeply ingrained concept of personal autonomy, and this is stigmatizing.
Japanese psychiatrists are thus reluctant to tell their
patients that they are suffering from schizophrenia,
and, as a result, no more than 20 percent of sufferers
actually do know about their diagnosis. Because taking
medication is based on informed consent and the exercise of the patient's autonomy, such lack of information has important negative effects. It is unlikely that
this problem can be resolved by education or information alone, and it may well be the case that in cultures
using ideographs, the illness will need to be renamed.
This article suggests some alternatives.
Keywords: Schizophrenia, term, splitting, ideograph, stigma
Schizophrenia Bulletin: 27(2): 181-185, 2001.
Figure 1. The Japanese translation of
"schizophrenia" Is selshln-bunretsu-byo
("mind-split-disease")
shin
sei
mind
bun
retsu
split
byo
disease
In Japanese, Chinese characters serve as lexical components in the same way that morphemes do in the
European languages. Chinese characters convey meaning
more directly than Western morphemes and are easily
understood by all users. In ordinary Japanese, seishin,
bunretsu, and byo are independent terms and in very com-
The term schizophrenia (Bleuler 1908) comes from the
Greek for "splitting of mental faculties." For complex
sociological reasons, this metaphor of the split mind has
become overworn and came to be accepted as if it were
actual fact in the West. Furthermore, those in the West
who do not know Greek are protected from any deeper
connotation of the term. In Japan and other Asian coun-
Sendreprintrequests to Dr. Y. Kim, Division of Adult Mental Health,
National Institute of Mental Health, NCNP, 1-7-3 Kohnodai, Ichikawa,
Chiba, 272-0827, Japan; e-mail: [email protected].
181
Schizophrenia Bulletin, Vol. 27, No. 2, 2001
Y. Kim and G.E. Berrios
mon daily usage. This is not the case at all in the West,
where schizein, phren, and -ia are not used as independent
words. From just glancing at seishin-bunretsu-byo, a
Japanese speaker will fully grasp the entire "meaning" of
schizophrenia. Connotations also become important at
this stage: for example, bunretsu ("split") by itself also
evokes a condition of "catastrophic disorganization."
When denotations and connotations are put together, the
result is a powerful and stigmatizing term.
The same is the case in other countries using ideographs. In China the term is perceived by ordinary people
as meaning "catastrophe of mind." In Korea it has a similar meaning even when the term is currently written in
hangul (the Korean alphabet to convey phonetic sounds of
Chinese characters). The total population of countries
using Chinese ideographs is about 1.4 billion, approximately a quarter of the world's population (United
Nations 1995).
The purpose of this article is to draw attention to the
fact that the current translation of "schizophrenia" into
Japanese generates a stigma that creates a practical problem in psychiatry that is far more acute than in the West
Because it is unlikely that education of the lay public
alone will correct this problem, the article suggests that
the disease may need to be renamed worldwide.
1999) surveyed the attitudes of Japanese clinicians toward
seishin-bunretsu-byo. Some believed that they should
continue using the term on the grounds that the term indicated a coexistence of sanity and insanity that, according
to some, is the central feature of the disease. But it was
also alleged that the term remained stigmatizing even
when the patient was in remission, as the potential for
falling back into "mental disorganization" was ever present. This fatalistic view of the disease (which is not present in Bleuler's original meaning) is likely to have been
encouraged by the semantic idiosyncratic connotation
attached to this disorder by the terms listed above.
Furthermore, in Japanese, pejorative derivatives of the
term are in usage (e.g., "the government is behaving in a
schizophrenic manner" to refer to a lack of coherence and
organization).
The Implication of Schizophrenia
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") (p. 6). At the beginning of the century,
"Spaltung" had acquired a technical meaning among psychiatrists with associationistic beliefs and gave rise to a
plethora of neologisms for schizophrenia: intrapsychic
ataxia, dementia dessecans, discordance, dementia sejunctiva, dysphrenia, discordance, and so forth. None ever
caught on (Berrios 1987). To Bleuler two mechanisms
were involved in "Spaltung": a deeper and more general
"primary loosening of associational networks" ("primare
Lockerung des AssoziationsgefUges"), which led to an
"irregular breaking" ("unregelmaBigen Zerspaltung") of
even "concrete concepts" ("konkreten Begriffe") and also
a more apparent "systemic splitting of idea-complexes"
("systematischen Spaltung in bestimmte Ideenkomplexe")
(Berrios 2000).
The neologism schizophrenia and its associated concept of "splitting" were not accepted by everyone. Freud
(1953) expressed some reservations about both, noting
that splitting "does not belong exclusively to that disease"
(pp. 9-82). Jaspers (1913) also commented that splitting
could not be observed in some schizophrenia patients.
After the Second World War, Ey (1954) suggested that
splitting is occasionally present in "normal" people.
Schneider (1946) called into question the view that
Bleuler's "fundamental symptoms" were the direct
expression of splitting. Schneider's own concept of schiz-
The Term Schizophrenia as a Source of
Stigma
Stigma is defined as "a mark of disgrace or infamy; a sign
of severe censure or condemnation, regarded as impressed
on a person or thing; a 'brand'" (OED 1989). In medicine,
stigmatization is a sociological process in which the mere
assignment of a medical category (e.g., a diagnostic label)
will result in negative consequences for a person. Social,
historical, and linguistic reasons explain why a particular
medical term or procedure may be stigmatizing. In the
field of psychiatry, an old example is hysteria. Association
of this disease with the uterus has made hysteria particularly stigmatizing to women. Neurosyphilis was equally
stigmatizing during the 19th century, as it evoked moral
connotations of sexual misbehavior and related to a period
of moral panic that during the 20th century has been
repeated in relation to AIDS. Seishin-bunretsu-byo is yet
another example: by conveying the vivid notion of a catastrophic split mind and of a loss of autonomy, the term
makes the patient feel diminished and have strong negative feelings about him- or herself, which undermines
consensual treatment.
In 1997, the Committee on Concepts and
Terminology of Psychiatric Diseases in the Japanese
Society of Psychiatry and Neurology (1996; Ono et al.
182
Schizophrenia Bulletin, Vol. 27, No. 2, 2001
At Issue
toms are meant to highlight the view that schizophrenia is
a "cerebral disease" and that splitting is relevant only to
secondary symptoms. Thus, it could be said that in etiological terms Bleuler was not fully committed to the concept of splitting.
A third cause of reluctance may be the belief that
renaming will not work because "schizophrenia" is used
by many people around the world. This belief may lead to
fatalism. This set of arguments would be acceptable if the
meaning of the term (i.e., that there is a "catastrophic
splitting of the mind") was in keeping with current science. One of the counterarguments put forward in this
article is that the term is not in keeping with current science. Renaming, therefore, is an option that would lead to
a more realistic understanding of the disease.
Of course, renaming would need to be accompanied
by a broad educational drive and by empirical research.
Something similar happened with Hansen's disease,
whose renaming predated the discovery of its pathogenesis.
Last, there is the question of whether cost-benefit
analysis renaming is more costly than stigmatization.
Because both sides of the equation are hard to quantify,
there is no fast answer here.
On the one hand, there is the issue of the role and
nature of "proper names": to some, they do not matter,
and, hence, renaming would be costly almost by definition; to others, proper names convey an idea about their
referent (i.e., they denote and connote). If the latter is the
case, then renaming of schizophrenia would be indicated,
for the proper name is conveying the wrong information.
On the other hand, there is the problem of quantifying stigmatization—that is, of directly measuring a
"devalued social identity." As far as we know, an instrument to measure stigmatization is not yet available. It is
unlikely that the measurement of proxy variables such as
self-esteem will be sufficient in this regard.
Be that as it may, our prediction is that renaming
would not cause major turmoil if properly undertaken
(from the top, as per the next editions of DSM or
ophrenia differs from Bleuler's and does not take into
account the mechanism of splitting. Its introduction into
American psychiatry (by DSM-IH, American Psychiatric
Association 1980) led to a gradual abandonment of the
Bleulerian view.
In scientific terms, the concept of splitting is no
longer important in relation to schizophrenia. Of 1,854
articles that had "schizophrenia" in their title and were
published between 1997 and 1998 (Medline search,
September 30, 1999), only 2 use "split" or "splitting" in
the old sense. Five others mention Bleuler but do not
touch upon "splitting," and the same is the case in two
other papers on "word association" (an experimental
approach pioneered by Jung). "Thought derailment" and
"loose associations," once considered the "clinical" manifestations of splitting, are now explained otherwise and no
longer considered as "pathognomonic" of schizophrenia
(Andreasen 1979). The same can be said of Bleuler's fundamental symptoms (now called "negative"), which are
no longer believed to result from splitting. All this suggests that there is no longer a reason for "splitting" to be
part of the name of the disease.
Explaining the Reluctance To Change
The Japanese survey also revealed that twice as many
Japanese psychiatrists are willing to give up the term
schizophrenia to those who are not. The fact that some
psychiatrists were reluctant to do so, however, requires
explanation, particularly if they were happy to accept
changes such as the change of "manic-depressive psychosis" to "affective disorder" and the change of "autism"
to "pervasive developmental disorder." One explanation
may be the belief that renaming threatens the existence of
the condition itself or that of the group of conditions to
which it belongs (endogenous psychoses). To Japanese
psychiatry (loyal to its German origins), the concept of
"endogenous psychoses" remains a cornerstone of the
identification of abnormal reactions (in Schneider's sense)
and the so-called neurosis. This view was strengthened by
an acceptance of Jaspers' belief in the incomprehensibility
of the psychotic experiences.
Another reason for reluctance may be social; that is,
traditional Japanese psychiatrists believe that abandoning
the term schizophrenia and its emblematic mechanism
"splitting" would be an insult to the memory of Bleuler
and also an abdication of his advice that psychotherapy
may be the main way of treating splitting.
But this does not need to be the case. Bleuler (1911)
introduced two classification dichotomies for the symptoms of the disease: fundamental versus accessory, and
primary versus secondary. Splitting happens to be an
important mechanism only to the former. Primary symp-
ICD-10).
Toward a Consent-Based Psychiatry
A consequence of the translational idiosyncrasies mentioned above is that Japanese psychiatrists are reluctant to
tell patients that they are suffering from schizophrenia.
For example, in five National Mental Hospitals in Japan,
only 16.6 percent of patients and 33.9 percent of their key
relatives knew about the diagnosis (in comparison, 90%
of patients and relatives knew about a diagnosis of "affective" or "neurotic" disorder) (table 1; Kim et al. 1997).
This difference cannot be fully explained in terms of a
183
Schizophrenia Bulletin, Vol. 27, No. 2, 2001
Y. Kim and G.E. Berrios
Table 1. Diagnoses known by schizophrenia patients and their family members (from five National
Mental Hospitals, Japan)
Diagnosis
% patient,
n=157
% family members,
n = 109
48.4
16.6
8.9
3.8
4.5
0.6
14.0
2.5
1.9
5.1
1.3
3.2
5.1
1.9
3.8
1.3
50.5
33.9
8.3
3.7
3.7
0.9
2.8
0.9
0.0
0.9
0.0
0.9
0.9
0.9
2.8
0.0
No knowledge
Schizophrenia
Affective disorder
Manic depressive
Depression
Mania
Neurosis
Psychasthenia
Anxiety neurosis
Autonomic nervous dysfunction
Obsessive-compulsive disorder
Neurosis (general)
Hallucination
Psychogenic reaction
Some psychiatric disorder
Other
putative "paternalism" within Japanese psychiatry. It does
sound very much as if the difference is due to a withholding of the diagnosis of schizophrenia. Be that as it may,
keeping patients ignorant of their diagnosis and prognosis
has disease management implications and violates their
rights. To add insult to injury, euphemisms such as
"neurasthenia" or "autonomic nervous dysfunction" seem
more common in the case of schizophrenia than with
other mental disorders. Euphemisms rarely work in practice; in this case, they lead to disinformation and interfere
with the right of patients to access the correct information
about their illness.
Some Japanese psychiatrists have attempted of late to
resolve the problem of translational connotations by creating a semantic or phonetic neologism. This solution has
worked acceptably in regard to diseases such as dystrophy, whose phonetic transcription in Japanese indicates a
place in the classification rather than a specific content.
Still, some psychiatrists feel that this solution is not faithful to the truth.
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.
Can the Disease Be Renamed?
Replacing the term schizophrenia, even at this late stage in
the history of psychiatry, is not an altogether nonsensical
proposition. Arguments in favor of the change have been
made for some time, and in some cases they originate from
concerns about the "reality" of schizophrenia (e.g.,
Brockington 1992). The case made in this article is not theoretical and stems from an issue affecting the perception of
the disease by a quarter of the world's population.
184
Schizophrenia Bulletin, Vol. 27, No. 2, 2001
At Issue
References
Jahrbuch fur psychoanalytische und psychopathologische
Forschungen, 3:9-68, 1911.
American Psychiatric Association. DSM-IH: Diagnostic
and Statistical Manual of Mental Disorders. 3rd ed.
Washington, DC: APA, 1980.
Jaspers, K. Allgemeine Psychopathologie. Heidelberg,
Germany: Springer, 1913.
Kim, Y; Kita, H.; Koishikawa, H.; Mizukawa, R.; and
Iwasaki, S. A survey of the current status of the informed
consent in psychiatric patients and their family members.
Psychiatria et Neurologia Japonica, 99:1259, 1997.
Andreasen, N.C. Thought, language, and communication
disorders: n. Diagnostic significance. Archives of General
Psychiatry, 36:1325-1330, 1979.
Andreasen, N.C. A unitary model of schizophrenia.
Archives of General Psychiatry, 56:781-787, 1999.
Ono, Y; Satsumi, Y; Kim, Y; Iwadate, T; Moriyama, I.;
Nakane, Y; Nakata, T; Okagami, T; Sakai, T; Sato, M.;
Someya, T; Takagi, S.; Ushijima, S.; Yamauchi, K.; and
Yoshimura, K. Schizophrenia: Is it time to replace the term?
Psychiatry and Clinical Neurosciences, 53:335-341,1999.
Berrios, G.E. The fundamental symptoms of dementia
praecox and Bleuler. In: Thompson, C , ed. The Origins of
Modern Psychiatry. New York, NY: John Wiley, 1987. pp.
200-209.
Schneider, K. Klinische Psychopathologie.
Germany: Georg Thieme, 1946.
Berrios, G.E. Schizophrenia: a conceptual history. In
Gelder, M.; Lopez-Ibor, J.J.; and Andreasen, N., eds. New
Oxford Textbook of Psychiatry, vol 1. Oxford, U.K.:
Oxford University Press, 2000. pp. 567-571.
Stuttgart,
United Nations. Demographic Yearbook. New York, NY:
United Nations, 1995.
Simpson, J., and Weiner, E. (eds). Oxford English
Dictionary, second edition. Oxford University Press,
Oxford, U.K., 1989.
Bleuler, E. Dementia Praecox oder Gruppe der
Schizophrenien. Leipzig, Germany, und Wien, Austria:
Franz Deuticke, 1911.
Bleuler, E. Die Prognose der Dementia Praecox—Schizophreniegruppe. Allegmeine Zeitschrift filr Psychiatrie,
65:436-464, 1908.
Acknowledgments
The authors would like to thank Professor Norman
Sartorius (Hdpitaux Universitaires de Geneve) for his
advice and encouragement; and Professors Zu-Cheng
Wang (Shanghai Second Medical University, China) and
Kang-Kyu Park (Seoul National Mental Hospital, Korea)
for providing information on stigmatization related to
schizophrenia in their countries.
Brockington, I. Schizophrenia: Yesterday's concept.
European Psychiatry, 7:203-207, 1992.
Committee on Concepts and Terminology of Psychiatric
Diseases in the Japanese Society of Psychiatry and
Neurology. Results of "questionnaire on the term and concept of schizophrenia: part 1." Psychiatria et Neurologia
Japonica, 98:245-265, 1996.
The Authors
Committee on Concepts and Terminology of Psychiatric
Diseases in the Japanese Society of Psychiatry and
Neurology. Results of "questionnaire on the term and concept of schizophrenia: part 2." Psychiatria et Neurologia
Japonica, 99:588-613, 1997.
Yoshiharu Kim, M.D., Ph.D., is Assistant Director of the
Division of Adult Mental Health, National Institute of
Mental Health, National Center of Neurology and
Psychiatry, Ichikawa, Japan; German E. Berrios, M.D.,
F.R.C.Psych., F.B.P.s.s., F.med. Sci., is Consultant and
University Lecturer in Neuropsychiatry, Senior Research
Fellow, Dept. of History and Philosophy of Science,
University of Cambridge, Cambridge, UK.
Ey, H. Etudes psychiatriques. Paris, France: Descl6e de
Brouwer, 1954.
Freud, S. Psychoanalytische Bemerkungen tlber einen
autobiographisch beschriebenen Fall von Paranoia.
185