Swan song for schizophrenia?

A bad wound will heal but a bad name will kill. —Scottish proverb Schizophrenia is a word that frightens people, is replete with stigma, is used pejoratively in daily speech and is ety-mologically absurd. There is now widespread international interest in In this Editorial, we examine the justification for giving up the term and consider strategies for finding an alternative. In a recent article, Lasalvia and Tansella (2013) point out that when Bleuler proposed the name schizo-phrenia in 1911, he was aware from the outset of the considerable diversity in its clinical manifestations (Bleuler, 1911, 1950). Bleuler gave primacy to dissociative pathology but also emphasized the importance of negative symptoms and interpersonal difficulties. This broadened the definition of schizophrenia, which was captured in the Diagnostic and Statistical Manual of Mental Disorders, First and Second Editions (DSM-I and DSM-II), and contributed the differences that emerged with respect to its diagnosis across Europe and the USA (Bleuler, 1950). Other key influences that shaped the definition of schizophrenia were the views of Kraepelin and Schneider. Kraepelin's perspective centred on avolition and emphasized longitudinal outcome and chronicity, whereas Schneider focused on the distortion of reality, which manifests as positive symptoms (Kraepelin, 1971; Schneider, 1959). Diverse views and inconsistencies in diagnosis prompted DSM-III to constrict the definition by giving prominence to Schneiderian first-rank symptoms, poor functioning and chro-nicity, so as to achieve greater homo-geneity. However, the criteria were once again loosened in subsequent editions of DSM, with the inclusion of negative symptoms, and by no longer stipulating onset before the age of 45 years. Arguably, DSM-IV schizophre-nia has been a useful term that has reasonable validity and high reliability (Tandon et al., 2009). As a diagnosis it has proven to be quite stable (Bromet et al., 2011) and hence DSM-5 has retained much of the core structure of DSM-IV schizophrenia. Interestingly, the 'classic' subtypes of schizophrenia appear to have fallen out of favour with clinicians and the majority of psychiatrists subtype their patients as having schizophrenia of a paranoid or undifferentiated form, if they do so at all. The remaining subtypes, namely catatonic and hebephrenic/disorgan-ized, are rarely, if ever, diagnosed and have little prognostic value (Linscott et al., 2010). But simply refining the definition of schizophrenia, both internally with respect to subtypes so as to diminish heterogeneity, and externally so as to demarcate its boundaries with adjacent constructs, is not enough. Schizoaffective disorder (SAD) is …