The British Journal of Psychiatry
1–2. doi: 10.1192/bjp.bp.114.146217
Short report
Renaming schizophrenia to reduce stigma:
comparison with the case of bipolar disorder
Nell Ellison, Oliver Mason and Katrina Scior
Summary
Renaming disorders to change public beliefs and attitudes
remains controversial. This study compared the potentially
destigmatising effects of renaming schizophrenia with the
effects of renaming bipolar disorder by comparing the label
‘schizophrenia’ to ‘integration disorder’, and ‘bipolar disorder’
to ‘manic depression’, in 1621 lay participants. ‘Bipolar disorder’
was associated with less fear and social distance than ‘manic
Whether schizophrenia should be renamed to help reduce stigma
has sparked debate among the scientific community.1–3 Some argue
that changing the name would help reduce iatrogenic stigma, as
schizophrenia has connotations of disease and ‘split-mind’.3 Others
maintain that stigma is due to the public’s ignorance and fear of
people with mental illness2 and better education, not a name
change, is what is necessary. In 2002, Japan changed their term
for schizophrenia from ‘split-mind-disease’ to ‘integration disorder’
in an effort to change public attitudes.4,5 Similarly, although not
directly aimed at changing attitudes, ‘manic depression’ was
officially changed to ‘bipolar disorder’ in 1980. This change has
been cited as an example of where changing terminology has
helped to reduce stigma.6 However, there is little empirical
evidence regarding renaming; whereas one study exploring the
effect of the Japanese name change reported a decrease in
endorsement of the stereotype ‘criminal’ among college students,5
two studies using small college student samples, in China and
Canada, found no difference between different terms presented
for schizophrenia.7,8 There have been no general population studies
exploring the effect of different labels for schizophrenia on public
beliefs and attitudes, and no studies exploring the effect of renaming
on all components of public stigma (i.e. cognitive, emotional and
behavioural reactions). No studies have explored the effect of the
name change in bipolar disorder on public beliefs and attitudes. This
study aimed to address these gaps in the literature for both disorders.
Method
We recruited 1621 UK residents using email, flyers and social
networking sites using an incentivised form of snowballing9 (see
online Table DS1 for sociodemographic characteristics). Of those
who accessed the site, 79.7% completed the online survey. We used
an experimental randomised cross-sectional design. Each participant
received two vignettes: one met DSM-IV10 and ICD-1011 criteria for
schizophrenia and was labelled either schizophrenia or integration
disorder, and the other met DSM-IV and ICD-10 criteria for
bipolar disorder and was labelled either bipolar disorder or manic
depression. Label pairing and presentation order were counterbalanced and participants randomly assigned. Vignettes were
reviewed by five experts for the purpose of masked diagnostic
allocation and to ensure they were deemed representative of the
target disorder and of equal severity.
After being presented with each vignette, respondents
completed questionnaires covering five aspects of public stigma:
causal beliefs, prognosis, emotional reactions, stereotypes and
behaviour (social distance). Derivations of the vignettes and the
depression’. ‘Integration disorder’ was associated with increased
endorsement of a biopsychosocial cause and reduced attributions
of dangerousness but also increased social distance,
highlighting the complex effects renaming has on stigma.
Declaration of interest
None.
public stigma questionnaire scales are given in the online supplement.
In the present sample, alpha coefficients were good to excellent for all
scales. To assess the influence of different diagnostic labels on beliefs
and attitudes, 26262 between-subjects ANOVAs were conducted
for each vignette separately. The inclusion of presentation order and
pairing as fixed factors allowed for the assessment of any interaction
effect with the effect of label. There was no interaction, indicating
that the effect of label did not vary depending on which label was
presented first or which label it was paired with. All P-values were
Bonferroni corrected for tests carried out within each questionnaire.
Results
‘Bipolar disorder’ v. ‘manic depression’
There was a significant difference between the two labels on all
causal beliefs, with psychosocial causes being ascribed more to
the label manic depression than to bipolar disorder (Table 1 and
online Table DS2 for means and standard deviations). Biomedical
causes were ascribed more to the label bipolar disorder than to
manic depression, and fate causes were ascribed more to the label
manic depression than to bipolar disorder. The label manic
depression elicited more fear and a greater desire for social
distance than bipolar disorder. There was no difference between
the two labels on prognosis without treatment or under optimal
treatment; compassion or anger; or on the stereotypes of
dangerousness, dependency, or intelligence and creativity.
Schizophrenia’ v. ‘integration disorder’
Psychosocial causes were ascribed more to the label integration
disorder than schizophrenia (Table 1 and online Table DS2).
The stereotype of dangerousness was ascribed more to the label
schizophrenia than to the label integration disorder. Conversely,
the label integration disorder elicited a greater desire for social
distance than schizophrenia. There was no difference between
the two labels on biomedical or fate causal beliefs; prognosis
without treatment or under optimal treatment; fear, compassion,
or anger; or on the stereotypes of dependency, or intelligence and
creativity.
Discussion
The influence of different diagnostic labels on stigma appears
complex. ‘Bipolar disorder’ was associated with less stigma on
some domains, with it reducing fear and desire for social distance.
‘Integration disorder’ had mixed effects, with it increasing
endorsement of psychosocial causes and reducing attributions
1
Ellison et al
Table 1 Effect of different diagnostic labels for bipolar
disorder and schizophrenia a
Bipolar disorder
Causal beliefs
Psychosocial
Biomedical
Fate
f
d
10.19**
12.85***
6.73*
0.16
0.20
0.14
Schizophrenia
f
8.68**
5.48
3.03
d
0.14
–
–
Prognosis
Without treatment
Under optimal treatment
0.56
0.38
–
–
0.99
0.02
–
–
Emotional reactions
Fear
Compassion
Anger
6.69*
0.17
0.04
0.14
–
–
2.19
1.07
0.44
–
–
–
Stereotypes
Dangerousness
Dependency
Intelligence/creativity
0.78
4.87
0.06
–
–
–
9.28**
1.21
3.96
0.15
–
–
Social distance
9.36***
0.16
5.43*
0.13
a. Bipolar disorder: n = 1569–1579; schizophrenia: n = 1566–1578; d.f. = 1, error
d.f. = 1558–1572.
*P50.05, **P50.01, ***P50.001.
dangerousness, while simultaneously increasing desire for social
distance. These significant findings all showed a small effect size
at best, yet the 1.6–3.4% change observed on these measures
compares favourably with Time to Change, the UK’s largest
anti-stigma campaign, which demonstrated a 1.4% improvement
on measures of attitudes and social distance since 2008.12 One
aim in the Japanese renaming of schizophrenia was to promote
a biopsychosocial model of causality.4 In our study, integration
disorder was ascribed more to psychosocial and less to biomedical
causes, suggesting this objective may be achieved if it were to be
renamed. The belief that people with schizophrenia are dangerous
is consistently cited as detrimental to their inclusion in society.
Findings suggest that, independent of behaviour, the term
schizophrenia may have a role to play in perpetuating this
stereotype. The label integration disorder had a negative effect
on social distance. Van Os3 proposed that the term integration
disorder may paradoxically induce stigma because the public
cannot relate to a universal psychological function of ‘integration’.
Research is therefore needed to explore alternative labels for
schizophrenia, such as ‘salience syndrome’.3 Integration disorder
was also the less familiar diagnosis, and familiarity is known to
reduce social distance.13
The more positive attitudes associated with ‘bipolar disorder’
may be due to the impact it had on causal beliefs. That is,
endorsement of biomedical beliefs have been found to have a
positive effect on stigma,14 whereas endorsement of fate causal
beliefs have a negative effect.15 It may also simply represent an
effect of iatrogenic stigma, with manic depression evoking
descriptions of people as ‘maniacs’. Renaming may also have
indirect effects on public stigma through the reduction of
internalised stigma. Specifically, it may have allowed people to
reject the negative stereotypes attached to manic depression,
subsequently promoting disclosure and therefore increasing
contact between people with bipolar disorder and the general
population. It may also have made those being disclosed to more
receptive to education by reducing initial assumptions. This study
does not support the assertion that any benefits of renaming are
short-lived as ‘bipolar disorder’ continues to be less stigmatised.
Indeed, any positive effects of renaming through changes in
2
internalised stigma, or through its interaction with education,
are likely to take time to become apparent.
This is the largest study to explore renaming and stigma, and
although the ethnicity of the sample was broadly representative
of the UK population, the sample was predominantly female
and educated to degree level, which may limit generalisability.
Importantly, though, neither gender nor educational attainment
predicted scores on social distance in the present sample.
The negative effect the term integration disorder had on social
distance suggests any decisions to rename should be made with
caution. However, a decision not to rename may overlook an
important opportunity to tackle damaging stereotypes and
promote a biopsychosocial model of causality. Finally, service users
and families have been campaigning for over 30 years to have the
term for schizophrenia changed.4 It is of paramount importance
that this is not ignored in any decision regarding renaming.
Nell Ellison, MA(Hons), DclinPsy, Oliver Mason, BSc, DClinPsy, PhD, Katrina Scior,
BSc, DClinPsych, PhD, Research Department of Clinical, Educational and Health
Psychology, University College London, London, UK
Correspondence: Nell Ellison, University College London, 66C Whitehall Park,
London N19 3TN, UK. Email: [email protected]
First received 9 Feb 2014, final revision 21 Sep 2014, accepted 29 Sep 2014
References
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psychiatry’s evidence-based entry into the 21st century? Acta Psychiatr
Scand 2009; 120: 363–72.
4 Sato M. Renaming schizophrenia: Japanese perspective. World Psychiatry
2006; 5: 53–5.
5 Takahashi H, Ideno T, Okubo S, Matsui H, Takemura K, Matsuura M, et al.
Impact of changing the Japanese term for ‘‘schizophrenia’’ for reasons of
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6 Kingdon D, Hansen L, Kinoshita Y, Naeem F, Rathod S, Swelam M, et al.
Schizophrenia can and should be renamed. Rapid response to Leiberman &
First ’Renaming Schizophrenia’. BMJ 2007; 334: 108 (http://www.bmj.com/
content/334/7585/108?tab = response-form).
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people with schizophrenia. Psychiatry Clin Neurosci 2004; 58: 507–15.
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The British Journal of Psychiatry (2015)
206, 1. doi: 10.1192/bjp.bp.114.146217
Data supplement
Table DS1
( n = 1474)
Method – sources of vignettes
and questionnaire scales
Sociodemographic characteristics of the sample
%
The schizphrenia vignette was based on Angermeyer et al13 and Jorm
et al;16 the bipolar disorder vignette was based on Wolkenstein &
Meyer.17
Seventeen items on causal beliefs were drawn from several
studies18–22 and submitted to an exploratory factor analysis that
led to three factors: psychosocial, fate and biomedical. Furnham
& Wardley23 supplied items of prognosis. Emotional reactions
were measured using the Emotional Reaction to Mental Illness
Scale.24–26 Stereotypes of perceived dangerousness and dependency
were measured using the Personal Attributes Scale.24 A third
stereotype of ‘intelligence/creativity’ was measured using three
items from Angermeyer & Matschinger.27 Desire for social
distance was measured with five items from Scior & Furnham22
and Link et al.28
Additional references
16 Jorm AF, Korten AE, Jacomb PA, Christensen H, Rogers B, Pollitt P. Mental
health literacy: a survey of the public’s ability to recognise mental disorders
and their beliefs about the effectiveness of treatment. Med J Aust 1997; 166:
182–6.
17 Wolkenstein L, Meyer TD. Attitudes of young people towards depression and
mania. Psychol Psychother 2008; 81: 15–31.
Gender
Male
Female
29.3
70.7
Ethnicity
White British
White Other
Black African/Black Caribbean
Asian
Other
75.8
13.4
2.7
5.1
2.9
Religion
Religious
Non-religious/atheist/agnostic
45.1
54.9
Education
Degree
No degree
75.2
24.8
Occupation
Studenta
Not student
30.0
70.0
Contact with bipolar disorder
Yes
No
43.6
56.4
Contact with schizophrenia
Yes
No
28.0
72.0
a. Includes A-level students.
18 Angermeyer MC, Matschinger H. Public beliefs about schizophrenia and
depression: similarities and differences. Soc Psychiatry Psychiatr Epidemiol
2003; 38: 526–34.
19 Furnham A, Anthony E. Lay theories of bipolar disorder: the causes,
manifestations and cures for perceived bipolar disorder. Int J Soc Psychiatry
2010; 56: 255–69.
24 Angermeyer MC, Buyantugs L, Kenzine DV, Matschinger H. Effects of labelling
on public attitudes towards people with schizophrenia: are there cultural
differences? Acta Psychiatr Scand 2004; 109: 420–5.
20 Jorm AF. Mental health literacy. Br J Psychiatry 2000; 177: 396–401.
25 Angermeyer MC, Holzinger A, Matschinger H. Emotional reactions to people
with mental illness. Epidemiol Psichiat Soc 2010; 19: 26–32.
21 Nieuwsma JA, Pepper CM. How etiological explanations for depression
impact perceptions of stigma, treatment effectiveness, and controllability
of depression. J Ment Health 2010; 19: 52–61.
26 Angermeyer MC, Matschinger H. The stigma of mental illness: effects of
labelling on public attitudes towards people with mental disorder. Acta
Psychiatr Scand 2003; 108: 304–9.
22 Scior K, Furnham A. The Intellectual Disability Literacy Scale (IDLS): a new
measure to assess knowledge, beliefs and attitudes to intellectual disability
and schizophrenia. Res Dev Disabil 2011; 32: 1530–41.
27 Angermeyer MC, Matschinger H. The stereotype of schizophrenia and its
impact on discrimination against people with schizophrenia: results from a
representative survey in Germany. Schizophr Bull 2004; 30: 1049–61.
23 Furnham A, Wardley Z. Lay theories of psychotherapy II: the efficacy of
different therapies and prognosis for different problems. Hum Relat 1991; 44:
1197–211.
28 Link BG, Phelan JC, Bresnahan M, Stueve A, Pescosolido BA. Public
conceptions of mental illness: labels, causes, dangerousness and social
distance. Am J Public Health 1999; 89: 1328–33.
Table DS2
Effect of different diagnostic labels for bipolar disorder and schizophrenia, means and standard deviations
Biolar disorder
Bipolar disorder
Schizophrenia
Manic depression
Schizophrenia
Integration disorder
Mean
s.d.
Mean
s.d.
P
Mean
s.d.
Mean
s.d.
P
Causal beliefs
Psychosocial
Biomedical
Fate
4.22
5.25
1.54
1.31
1.18
0.75
4.43
5.01
1.65
1.28
1.29
0.84
0.003**
50.001***
0.03*
4.11
5.39
1.53
1.32
1.18
0.75
4.29
5.24
1.60
1.22
1.17
0.82
0.009**
0.057
3.03
Prognosis
Without treatment
Under optimal treatment
2.19
5.83
1.13
1.04
2.23
5.81
1.15
1.06
0.94
1.06
1.64
5.56
0.88
1.07
1.68
5.56
0.90
1.10
0.64
1.92
Emotional reactions
Fear
Compassion
Anger
2.29
5.03
2.20
1.17
1.23
1.22
2.46
5.00
2.19
1.26
1.22
1.21
0.03*
2.04
2.52
3.31
5.58
1.88
1.44
1.03
0.97
3.29
5.53
1.91
1.45
1.04
0.99
2.19
0.90
2.53
Stereotypes
Dangerousness
Dependency
Intelligence/creativity
3.55
3.40
4.01
1.06
1.26
1.34
3.51
3.52
3.98
1.09
1.25
1.31
1.11
4.87
2.37
4.16
3.73
3.73
1.24
1.31
1.25
3.98
3.66
3.61
1.24
1.28
1.24
0.006**
2.14
0.14
Social distance
3.46
1.36
3.68
1.40
0.002**
4.43
1.44
4.61
1.43
0.02*
*P50.05, **P50.01, ***P50.001. All P-values were Bonferroni corrected.
1
Renaming schizophrenia to reduce stigma: comparison with the
case of bipolar disorder
Nell Ellison, Oliver Mason and Katrina Scior
BJP published online January 8, 2015 Access the most recent version at DOI:
10.1192/bjp.bp.114.146217
Supplementary
Material
Supplementary material can be found at:
http://bjp.rcpsych.org/content/suppl/2015/01/06/bjp.bp.114.146217.DC1
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