BMJ 2016;352:i375 doi: 10.1136/bmj.

i375 (Published 2 February 2016)

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Views & Reviews

VIEWS & REVIEWS

PERSONAL VIEW

Schizophrenia does not exist

Disease classifications should drop this unhelpful description of symptoms
Jim van Os full professor and chair, Department of Psychiatry and Psychology, Maastricht University
Medical Centre, PO Box 616, 6200 MD Maastricht, Netherlands
In March 2015 a group of academics, patients, and relatives
published an opinion piece in a national newspaper in the
Netherlands, proposing that we drop the essentially contested1
term schizophrenia, with its connotation of hopeless chronic
brain disease, and replace it with something like psychosis
spectrum syndrome.2
We launched two websites (www.schizofreniebestaatniet.nl/
english/ and www.psychosenet.nl) aimed at informing the public
about the nature of psychotic illness and helping patients deal
with pervasive, unscientifically pessimistic, organic views of
their symptoms. The timing was no coincidence.
Several recent papers by different authors have called for
modernised psychiatric nomenclature, particularly regarding
the term schizophrenia.3-6 Japan and South Korea have already
abandoned this term.

Current classifications

The classification of mental disorders, as laid down in ICD-10

(International Classification of Diseases, 10th revision) and
DSM-5 (Diagnostic and Statistical Manual of Mental Disorders,
fifth edition), is complicated, particularly psychotic illness.

Currently, psychotic illness is classified among myriad

categories, including schizophrenia, schizophreniform disorder,
schizoaffective disorder, delusional disorder, brief psychotic
disorder, depression/bipolar disorder with psychotic features,
substance induced psychotic disorder, and psychotic disorder
not otherwise classified. Categories such as these do not
represent diagnoses of discrete diseases, because these remain
unknown; rather, they describe how symptoms can cluster, to
allow grouping of patients.
This elegant solution allows clinicians to say, for example, You
have symptoms of psychosis and mania, and we classify that
as schizoaffective disorder. If your psychotic symptoms
disappear we may reclassify it as bipolar disorder. If, on the
other hand, your mania symptoms disappear and your psychosis
becomes chronic, we may re-diagnose it as schizophrenia.
That is how our classification system works. We dont know
enough to diagnose real diseases, so we use a system of
symptom based classification. The DSM-5 does this differently

than ICD-10but that does not matter, because its only a

classification.

If everybody agreed to use the terminology in ICD-10 and

DSM-5 in this fashion, there would be no problem. However,
this is not what is generally communicated, particularly
regarding the most important category of psychotic illness:
schizophrenia.

The American Psychiatric Association, which publishes the

DSM, on its website describes schizophrenia as a chronic brain
disorder, and academic journals describe it as a debilitating
neurological disorder,7 a devastating, highly heritable brain
disorder,8 or a brain disorder with predominantly genetic risk
factors.9

Current language suggests discrete

disease
This language is highly suggestive of a distinct, genetic brain
disease. Strangely, no such language is used for other categories
of psychotic illness (schizophreniform disorder, schizoaffective
disorder, delusional disorder, brief psychotic disorder, and so
on). In fact, even though they constitute 70% of psychotic illness
morbidity (only 30% of people with psychotic illness have
symptoms that meet the criteria for schizophrenia),10 these other
categories tend be ignored in the academic literature (see box)
and on websites of professional bodies. They are certainly not
referred to as brain disorders or similar. Its as if they dont
exist.

What remains is the paradox that 30% of psychotic illness

morbidity is portrayed as a discrete brain disease; the other 70%
of the morbidity is communicated only in classification manuals.

Psychosis susceptibility syndrome

Scientific evidence indicates that the different psychotic
categories can be viewed as part of the same spectrum syndrome,
with a lifetime prevalence of 3.5%,10 of which schizophrenia
represents the minority (less than a third) with the poorest
outcome, on average. However, people with this psychosis
spectrum syndromeor, as patients have recently suggested,

vanosj@gmail.com
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BMJ 2016;352:i375 doi: 10.1136/bmj.i375 (Published 2 February 2016)

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VIEWS & REVIEWS

psychosis susceptibility syndrome6display extreme

heterogeneity, both between and within people, in
psychopathology, treatment response, and outcome.

The best way to inform the public and provide patients with
diagnoses, therefore, is to forget about devastating
schizophrenia as the only category that matters and start doing
justice to the broad and heterogeneous psychosis spectrum
syndrome that really exists.
ICD-11 should remove the term schizophrenia.

Competing interests: I have read and understood the BMJ policy on

declaration of interests and declare the following interests: in the past
five years, the Maastricht University psychiatric research fund that I
manage has received unrestricted investigator led research grants or
recompense for presenting research from Servier, Janssen-Cilag, and
Lundbeck, companies that have an interest in the treatment of psychosis.
Provenance and peer review: Not commissioned; externally peer
reviewed.

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1
2
3
4
5
6
7
8
9
10

Geekie J, Read J. Making sense of madness: contesting the meaning of schizophrenia.

Routledge, 2009.
Van Os J, Boevink W, Van der Gaag RJ, et al. Laten we de diagnose schizofrenie vergeten
[Lets forget about the diagnosis of schizophrenia]. NRC Handelsblad 2015 Mar 7. www.
chapeau-woonkringen.nl/documenten/artikelen/150307_NRC_Jim_van_Os.pdf. (In Dutch.)
Henderson S, Malhi GS. Swan song for schizophrenia? Aust N Z J Psychiatry
2014;48:302-5.
Lasalvia A, Penta E, Sartorius N, Henderson S. Should the label schizophrenia be
abandoned? Schizophr Res 2015;162:276-84.
Moncrieff J, Middleton H. Schizophrenia: a critical psychiatry perspective. Curr Opin
Psychiatry 2015;28:264-8.
George B, Klijn A. A modern name for schizophrenia (PSS) would diminish self-stigma.
Psychol Med 2013;43:1555-7.
Brennand KJ, Simone A, Jou J, et al. Modelling schizophrenia using human induced
pluripotent stem cells. Nature 2011;473:221-5.
Esslinger C, Walter H, Kirsch P, et al. Neural mechanisms of a genome-wide supported
psychosis variant. Science 2009;324:605.
Goldman AL, Pezawas L, Mattay VS, et al. Widespread reductions of cortical thickness
in schizophrenia and spectrum disorders and evidence of heritability. Arch Gen Psychiatry
2009;66:467-77.
Perala J, Suvisaari J, Saarni SI, et al. Lifetime prevalence of psychotic and bipolar I
disorders in a general population. Arch Gen Psychiatry 2007;64:19-28.

Cite this as: BMJ 2016;352:i375

BMJ Publishing Group Ltd 2016

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BMJ 2016;352:i375 doi: 10.1136/bmj.i375 (Published 2 February 2016)

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VIEWS & REVIEWS

Number of PubMed hits with specific diagnostic categories in the title (November 2015)
Schizophrenia: 51 675
Schizoaffective disorder: 1170
Schizophreniform disorder: 216
Delusional disorder: 212
Brief psychotic disorder: 17
Psychotic disorder (not otherwise specified): 5
Bipolar disorder with psychotic features: 1201
Depression with psychotic features: 409
Substance induced psychotic disorder: 28

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