Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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