Rebranding Psychiatry: Euphemisms, Stigma, and Progress
Revising the nomenclature of psychiatry
Posted Dec 18, 2014
“What's in a name? That which we call a rose
By any other name would smell as sweet”
-- William Shakespeare (Romeo & Juliet, Act II, Scene II)
“Rose is a rose is a rose is a rose.”
-- Gertrude Stein, Sacred Emily
Psychiatrists around the world have recently organized around an effort to reclassify the major categories of psychiatric medications based on a new four-part multiaxial system for individual medications to include a drug’s mechanism of action, approved indications, a summary of efficacy for both on- and off-label indications along with side effects, and a description of neurobiology.1 This effort is based on the idea that our existing names for medications – antidepressants, anxiolytics, antipsychotics – are at best misleading such that an update based on the current state of knowledge and clinical use is long overdue.
Indeed, things were seemingly much simpler 20 years ago. If someone had depression, they were given an antidepressant, usually a tricyclic or a mono-amine oxidase inhibitor. If someone was psychotic, they were prescribed an antipsychotic, also called a “neuroleptic,” referring to common motor side effects like stiffness or tremor. If a patient had manic-depression, lithium was the default option.
But ever since the advent of the serotonin reuptake inhibitors (SSRI) in the late 1980’s, better-tolerated antidepressants with demonstrated efficacy in a wider range of disorders have been increasingly used in patients without depression. For example, these days a person with social phobia or anorexia might very well be treated with an SSRI. In the 1990’s, a new generation of antipsychotic medications with a lower risk of motor side effects spawned years of debate about what to call them – “novel” antipsychotics, “atypicals,” and finally “second-generation antipsychotics (SGA).” Most of the SGA medications now have an FDA indication for some aspect of bipolar disorder and are used for a variety of other off-label conditions such that the term antipsychotic is too narrow for the scope of disorders for which these medications are typically prescribed. Anticonvulsant drugs, originally developed to control seizures, are routinely used for the treatment of bipolar disorder as well, leading to the broader term “mood stabilizer.” Suffice it to say that it can be a confusing world for someone being prescribed a psychiatric medication – the days when antidepressants were only for people with depression or when antipsychotics were only for people with psychosis are gone. The new nomenclature for medications, which is now available as a downloadable app called “NbNomenclature,” aims to reduce this confusion.
No doubt, there will be some who suspect that by renaming categories of psychiatric medications, psychiatry is engaging in a kind of deliberate shell game aimed at rebranding them in a more appealing way to a wider consumer base. That concern may be valid up to a point – there’s no doubt that the pharmaceutical industry, like any other sales-driven industry, cares a lot about the psychology of marketing and name brand associations, both positive and negative. When the SGAs came along with their lower risk of motor side effects, there was a directed effort by their makers to leave behind the term “neuroleptic” that had been synonymous with antipsychotic medications. Likewise, after the SGAs became available as long-acting injectable preparations, the old term “depot neuroleptic” was abandoned in favor of the more accurate term, “long-acting injectable.” While these changes were indeed deliberate efforts to get away from negative associations with older brands, they also better described the new products, both in terms of how they worked as well as their expected side effects.
Revisions to the nomenclature of psychiatry aimed at moving beyond negative connotations are not new and have occurred through the years not only for medications, but also for psychiatric disorders themselves. In the early 1900’s, “idiot,” “imbecile,” and “moron” were medical terms used to describe different levels of intellectual impairment. The term “cretin” originally described someone with impaired mental functioning related to congenital hypothyroidism, while the term “mongoloid” was used for someone with what we would now call Down’s syndrome. Despite the neutral intent of such terms in medicine, their misappropriation as pejoratives by the general public became widespread and remain so to this day. As a result, “mental retardation” was adopted as a more acceptable general term for impaired intellectual functioning. Although it was used for several decades in the Diagnostic and Statistical Manual (DSM), “retarded,” like “idiot” and “cretin” before it, also became a pejorative in lay speech such that the newest DSM-5 has recently adopted the term “intellectual developmental disorder” in its place.
In his book Blank Slate, psychologist Steven Pinker calls this cycle of a neutral word taking on a pejorative meaning, only to be replaced by a neutral term that eventually also becomes a pejorative, as a “euphemism treadmill.” The implication is that euphemistic name changes may be futile in the long run. While replacing the term “mentally retarded” with “intellectually disabled” was well intentioned, there have already been suggestions that words like “challenged” might be more suitable than “disabled.” And so on.
Several years ago, I wrote a paper about the revision of the diagnostic criteria for schizophrenia in which I commented on proposals to find a new name for the disorder. I noted that changing the name for schizophrenia would probably not fix its association with stigma because “the stigma associated with schizophrenia arises mainly because of our inability to treat it effectively” rather than because of the name itself.2 In other words, the best remedy to erase stigma associated with a mental illness is to improve its treatment and in doing so remove associations with poor functioning and low prospects of recovery. Inasmuch as that is possible, it would go a much longer way towards combating stigma than changing names ever could.
Nonetheless, some countries have forged ahead in abandoning the term “schizophrenia” in an attempt to combat stigma. For example, in Japan, after much debate, the Japanese Society of Psychiatry and Neurology replaced the old term for schizophrenia, “seishin-buretsu-byo” (“mind-split-disease”) with a new term “togo-shitcho-sho” (“integration disorder”). While preliminary surveys suggested that name changes like this can indeed reduce stigma,3,4 it may be that any such benefits reflect only temporary ignorance about a new term, with old stigma becoming associated with the new name in time. Simply finding a new name for the same thing may have limited utility in changing people’s negative attitudes, with new euphemisms inevitably becoming dysphemisms in an endless cycle.
Instead, name changes make the most sense when there has also been a fundamental change in the thing being named. New classifications for new medications are therefore reasonable, but calling an “antipsychotic” a “dopamine antagonist” won’t erase concerns about side effects like tardive dyskinesia and weight gain so long as such side effects remain a problem. Likewise, with psychiatric diagnosis, replacing “manic depressive disorder” with “bipolar disorder” or “schizophrenia” with “integration disorder” probably has limited utility as an upgrade until psychiatry can do something else to significantly change the prognosis of those conditions.
In certain cases however, rather than changing the names of disorders, it has been appropriate to get rid of some mental disorders altogether. For example, DSM-II included the diagnosis of “inadequate personality” to describe a person who displays “ineffective responses to emotional, social, intellectual, and physical demands” while manifesting “inadaptability, ineptness, poor judgment, social instability, and lack of physical or emotional stamina.” The lack of specificity of this constellation of symptoms notwithstanding, it was a diagnosis that no one could possibly be comfortable accepting based on its name alone. DSM-III rightly removed inadequate personality from its pages, while embracing more reliable, if still imperfect, concepts such as dependent personality disorder.
Much of the stigma specific to psychiatric disorders stems from the fact that psychiatric disorders affect the essence of a person. As Mark Vonnegut (author of Just Like Someone With Mental Illness, Only More So and the late Kurt Vonnegut’s son) wrote in his memoir, The Eden Express:
“Most diseases can be separated from one’s self and seen as foreign intruding entities. Schizophrenia is very poorly behaved in this respect. Colds, ulcers, flu, and cancer are things we get. Schizophrenia is something we are.”5
Since all medical diagnoses carry an element of cultural judgment about what’s good and bad, there’s always a certain negative valence attached to the concept of disease. Yet it’s much easier to accept a negative value judgment about our bodies than to accept a negative judgment about our brains. No one wants to hear news that you have a “bad heart,” but at least it may be correctable with medications, surgery, or even a transplant. If you have a psychiatric disorder however, the implication is that you are broken. Even if you were somehow able to get a brain transplant, you wouldn’t be you anymore. In that sense, being diagnosed with a mental illness requires a different kind of acceptance that’s much harder to swallow.
As advocates for our patients, psychiatrists must continue play an active role in fighting the stigma associated with mental illness. We can do this through the occasional name change if need be and by improving the prognosis of mental disorders through research and clinical work. In Making the DSM-5: Concepts and Controversies, I have also called for an expanded focus of psychiatry to the full spectrum of mental health in lieu of our historical focus only on disorders.6 That vision is the spirit of this blog, which aims to highlight the “psychiatry of everyday life” and to illustrate how all of us have experiences that are reminiscent of more serious and enduring mental disorders.
But psychiatry can only do so much. Stigma is primarily dictated by culture, such that greater sensitivity towards those with mental illness should not be dismissed as political correctness. Perhaps the greatest hope for reducing stigma lies in the fact that the individuals who have mental illness can themselves play a key role. Take “borderline personality disorder.” While this is among the most stigmatized conditions in psychiatry, with “borderline” often used as a pejorative among clinicians, I’ve seen some patients come to accept and even embrace this diagnosis after a careful, nonjudgmental explanation about what it really means and how it might account for years of difficulty with chaotic moods. In a similar fashion, after DSM-5 relegated “Asperger’s disorder” to the larger umbrella category of “autism spectrum disorder,” there was considerable outcry from the “Aspie” community that they’d lost a part of their individuality.
So it seems that stigma can be determined not only by labels but how we wear them, just as the term “gay” has seemingly come full circle from a synonym for happy and carefree, to a derogatory name for homosexuality, to a potential source of pride and increasing mainstream acceptance. Andrew Solomon, author of Far From the Tree: Parents, Children, and the Search of Identity, recently explained it this way in a TED Radio Hour podcast called Identities:
“As long as you experience your condition as an illness, it's a prison. And once you experience it as an identity, it's the source of your freedom. And I think that insofar as we can treat illnesses as identities, we liberate people into experiences of great joy that would otherwise be closed to them. And I think that therefore there's a real moral imperative to give people the right to claim whatever quality they have as an identity. I think it’s the only kind way to build a society.”7
And so, what’s in a name or a psychiatric diagnosis? In the end, only what we – that is, psychiatrists, patients, and society… all of us – make of it.
2. Pierre JM. Deconstructing schizophrenia for DSM-V: Challenges for clinical and research agendas. Clinical Schizophrenia & Related Psychoses 2008; 2:166-174.
3. Takahashi H, Ideno T, Okubo S et al. Impact of changing the Japanese term for “schizophrenia” for reasons of stereotypical beliefs of schizophrenia in Japanese youth. Schizophrenia Research 2009; 112:149-152.
4. Kingdon D. Vincent S, Vincent S et al. Destigmatising schizophrenia: does changing terminology reduce negative attitudes? Psychiatric Bulletin 2008; 32:419-422.
5. Vonnegut M. The Eden Express. Bantam Books: New York, 1975.
6. Pierre JM. Overdiagnosis, underdiagnosis, synthesis: A dialectic for psychiatry and the DSM. In: Paris J, Philips J, eds. Making the DSM-5: Concepts and Controversies. Springer: New York, 2013.