Linguistic and (micro)cultural differences in the global debate about re-naming ‘schizophrenia ’ : A mixed-methods survey from Switzerland

Background and hypothesis: This survey explores Swiss mental health professionals', users', and relatives' opinions on re-naming schizophrenia exploiting Switzerland's specific multilingualism to examine possible effects of linguistic and microcultural differences on the issue. Study design: Opinions on ‘schizophrenia ’ were collected using a self-rated online questionnaire incl. Freetext answers available in the three main Swiss languages, German, French and Italian. It was distributed to the main professional and self-help organizations in Switzerland between June and October 2021. Study results: Overall, 449 persons completed the questionnaire, 263 in German, 172 in French and 14 in Italian. Of the total sample, 339 identified as mental health professionals, 81 as relatives and 29 as users. Considering the whole sample, almost half favored a name-change with a significant difference between stakeholder-and be-tween language groups. Also, the name ‘schizophrenia ’ was evaluated more critically than the diagnostic concept. Qualitative analysis of freetext answers showed a highly heterogenous argumentation, but no difference between language groups. Conclusions: Our results suggest the attitude towards re-naming might itself be subject to (micro)cultural difference, and they highlight the nature of ‘schizophrenia ’ as not only a scientific, but also a linguistic and cultural object. Such local factors ought to be taken into consideration in the global debate.


Introduction
Naming mental disorders has always been a matter of debate.This is especially true of 'schizophrenia' 2 : In 1902, Eugen Bleuler defended Emil Kraepelin's 'dementia praecox' arguing: "To be sure, the name is not well chosen; but the question is only that of a nomen et flatus vocis and not of the thing.To waste words about it is, therefore, useless" (Bleuler, 1902).Ironically, in 1908, Bleuler introduced the new word 'schizophrenia' into psychiatric discourse.'Schizophrenia' however was not just a new name for the same "thing": It involved a re-conceptualization of the disorder aiming to be true to its course, which Bleuler believed to not necessarily lead to a dementia as 'dementia praecox' suggests, and to adequately capture its psychopathology (Maatz and Hoff, 2014).The name itself was also carefully chosen one of Bleuler's concerns being the possibility to form an adjective (Bleuler, 1911, 4;Ilg, 2019).Despite initial skepticism (Bernet, 2013, 16;Bleuler, 1908), 'schizophrenia' steadily replaced 'dementia praecox' first in Switzerland, then in Europe and finally around the globe.'Schizophrenia' also travelled into everyday language where a semantic shift took place (Ilg, 2021b(Ilg, , 2019(Ilg, , 2021a)): Besides being used as a slur, 'schizophrenia' is nowadays also employed to describe an action or attitude as absurd or self-contradictory (Dudenredaktion, 2022;Larousse Dictionnaire de Français, 2022;Merriam-Webster, 2022;Zingarelli, 2021).This development, which can be observed in many languages (Athanasopoulou and Sakellari, 2016;Athanasopoulou and Välimäki, 2014;Cain et al., 2014;Dubugras et al., 2011;Goulden et al., 2011;Kara and Kara, 2022;Park et al., 2012;Thys et al., 2013;Wahl et al., 1995), was met with criticism by psychiatrists, relatives and users alike.More generally, 'schizophrenia' was increasingly considered problematic due the stigma associated with it (Gaebel et al., 2002;Howe et al., 2014;Lasalvia, 2018;Lasalvia et al., 2021;Sheehan et al., 2017;Thomas et al., 2013).In 2002, Japan took action and changed the name, notabene a Japanese translation of the Greek 'schizophrenia' from, translated into English, mind-split-disease to integration disorder (Kim, 2002;Maruta and Matsumoto, 2017).The re-naming was accompanied by information campaigns disseminating present-day knowledge of course and outcome, treatment options, and rehabilitation potential (Sato, 2006;Umehara et al., 2011).Whilst opinions on the re-namings' success are heterogenous (Guloksuz and van Os, 2019;Koike et al., 2017;Lasalvia et al., 2021;Sartorius et al., 2014;Sato, 2017;Takahashi et al., 2009;Takahashi et al., 2011;Yamaguchi et al., 2017), other East-Asian countries followed suit and replaced the old translations of 'schizophrenia' in their respective languages by newer descriptions of the disorder (Maruta and Matsumoto, 2017).In the wake of the revisions of the DSM (American Psychiatric Association., 2013) and the ICD (World Health Organization, 2022) and with increasing organization and visibility of users and relatives, the debate about re-naming 'schizophrenia' went global.Besides the term's stigma, the scientific validity of the concept was now also seen as problematic (Jablensky, 2010;Heckers et al., 2013) and some authors blatantly stated that "schizophrenia doesn't exist" (Van Os, 2016).Despite these criticisms, the makers of DSM-5 and ICD-11 re-included 'schizophrenia' with minimal conceptual changes and left the name untouched (Tandon et al., 2013).The debate about a name change however goes on, and over roughly the past decade, several surveys in different countries and global regions have been conducted to empirically investigate attitudes towards 'schizophrenia' and a potential name change (Lasalvia et al., 2021;Maruta and Iimori, 2008;Roelandt et al., 2020;Mesholam-Gately et al., 2021).Some surveys suggest a clear preference for a name change whilst others show more heterogenous opinions on the issue.Psychiatric professionals are equally divided with some considering a name change mere "semantics" (Lieberman and First, 2007;Corrigan, 2016) or "wordplay" (Gaebel and Kerst, 2019), whilst others consider it an adequate means to combat stigma (Chiu et al., 2021;Lasalvia, 2018;Lasalvia et al., 2021;Mesholam-Gately et al., 2021).
What can another survey add to this debate?Besides adding a voice from a country that has up-to-now not been studied with regards to the issue of re-naming, our survey exploits Switzerland's specific multilingualism to examine possible effects of linguistic and microcultural differences on the issue.It thus adds an explicit consideration of local factors to this global debate.Furthermore, it follows Bleuler in distinguishing between "name" and "thing".Whilst the important conceptual difference between the name 'schizophrenia' on the one hand and the diagnostic concept schizophrenia on the other hand has often been acknowledged (Gaebel and Kerst, 2019;Tandon et al., 2009), this differentiation has up-to-now not been made when studying opinions on re-naming.With this paper, we thus hope to show that the debate about name change is not a waste of words, but can indeed "become the first step that allows catalysation of the process of modernizing psychiatric science and services worldwide" (Guloksuz and van Os, 2019).

Study design and participants
A mixed-methods online-survey was conducted amongst mental health professionals (psychiatrists, psychologists, nurses and others, referred to as "MHP" in the following), psychiatric service users as well as their relatives in Switzerland between June and October 2021.In total, 449 persons responded to the questionnaire.

Study region
Switzerland is a country situated in central Europe.A specific feature of Switzerland is its multilingualism: The majority (62.3 %) speak (Swiss)German as main language, 22.8 % speak French and 8 % Italian.A fourth official language, Romansh, is spoken by 0.5 % of the population.The remaining 23.1 % speak none of the official languages (Bundesamt für Statistik, 2022).

Instrument
For this survey, a self-rating questionnaire on use of and opinions on the term 'schizophrenia' used by Maruta et al. (2014) and Lasalvia et al. (2021) was adapted to the specific research interest and regional context: In the first part, socio-demographic information (age, level of education and gender) was gathered alongside information about professional resp.experiential background.We furthermore asked relatives about their relationship to the person diagnosed with schizophrenia, and we inquired about involvement in self-help groups.In a second part, participants were instructed to write down up to six spontaneous associations with 'schizophrenia' before in a third part being asked about their use of the terms 'schizophrenia', 'schizophrenic', and 'the schizophrenic'.Those two parts of the questionnaire, however, will be handled in a follow-up publication focusing specifically on the use of the terms.
Finally, participants were asked about the appropriateness of 'schizophrenia', about their opinion on changing the name and/or the diagnostic concept, and about their perceived association of name and concept respectively with stigma, and if in favor of a name change, they were asked to suggest alternative names (this latter part will equally be presented in a separate publication).To gain a differentiated understanding of the arguments underlying the reported use and opinions, freetext answers were invited for all questions.
The questionnaire was available in the three main Swiss languages, German, French and Italian, as well as in three different versions for the three stakeholder groups.The term 'schizophrenia' was translated 'Schizophrenie'/'schizophrénie'/'schizofrenia', and the associated adjective (schizophrenic) and its substantivized form (the schizophrenic) likewise.
The questionnaires were piloted on psychiatrists, mental health service users, relatives and members of society without any specific relation to 'schizophrenia' and their inputs were implemented to ensure comprehensibility and feasibility.

Procedures
The online-questionnaires were created with LimeSurvey (Limesurvey GmbH, 2006).Invitations to participate plus the link to the online-questionnaire were sent electronically to a large number of networks and institutions to reach the three stakeholder groups: MHP were recruited through two main professional bodies (Swiss association for psychiatry and psychotherapy SGPP, and Swiss association of directors of psychiatric hospitals SVPC) as well as by direct contact to major psychiatric hospitals in the three linguistic regions; users were recruited via all registered self-help groups related to 'schizophrenia'; and relatives were recruited via the two main networks of relatives (Network Relative Support in Psychiatry NAP, and Association of Relatives of Mentally Ill People VASK).

Statistical analysis
First, simple descriptive statistics were provided to characterize the entire study sample.Frequencies and percentages were reported for categorical variables and means (M) and standard deviations (SD) for continuous variables.
Furthermore, we explored whether stakeholder group membership and linguistic region (predictor variables) were linked to the primary outcomes (opinion on the term's and concept's adequacy and on whether 'schizophrenia' should be re-named).For this purpose, we calculated Chi-square statistics and bivariate logistic regressions with odds ratios (OR) and 95 % confidence intervals (95%CI) to indicate the degree of association between predictors and outcome.In predictor variables the categories "MHP" and "German language region" served as reference categories while not agreeing to an opinion served as reference in outcome variables.In the next step, we fitted a series of multivariate logistic regression for those models with significant predictor candidates from the previous bi-variate step to predict agreement to the outcomes of interest.All multivariate models were adjusted for gender and age per default (results not tabulated).
Finally, point-biserial correlations were calculated between opinions to illustrate raw associations between outcomes.

Qualitative analysis
Freetext answers were analyzed according to the principles of thematic analysis (Braun and Clarke, 2006), a method for qualitative data analysis that allows to identify and report thematic patterns for further interpretation.Our leading analytic question was "What arguments are provided for and against the name and concept 'schizophrenia'?".After reading, re-reading and initially coding, i.e. assigning words or short phrases that capture the essence of a portion of text (Saldana, 2015, 4) to the answers, there appeared strong thematic overlaps between answers to individual questions.We thus collated the answers for further analysis.Codes were grouped and systemized into higher-order themes and the emerging coding system was discussed at various data sessions amongst AL, YI and AM, a medical student, a linguist and a psychiatrist and philosopher respectively.It was then applied to the entire data set by AL and continually adapted when necessary.Exemplary as well as unclear passages were discussed amongst the researchers at further data sessions to reach consensual coding (Kuckartz, 2016;Becker et al., 2019).
Our interpretation rests on the triangulation of the results from the statistical and the results from the qualitative analysis, i.e. it brings these results in dialogue with each other seeking to reach a more nuanced understanding of the findings (Mertens and Hesse-Biber, 2012).

Ethics
As the survey was anonymous and participants' IP addresses were not stored, the study did not need ethical review.

Sample characteristics
Demographic and other relevant characteristics of the sample (n = 449) are shown in Table 1.The average age was 47.7 years (SD = 13.9;range 18-86 years) and 64.7 % identified as female.Regarding educational level, almost three quarters of the sample held a university degree.Therefore, for further analyses, education was dichotomized as university degree vs other.Regarding stakeholder group, most participants identified as MHP (75.5 %), followed by relatives (18 %), followed by service users (6.5 %).Of the MHP, most were nurses (33.5 %) or boardcertified psychiatrists (30.5 %), 10.6 % identified as psychiatric residents, 8.8 % as psychologists and 16.6 % declared other mental health professions (e.g.social workers, occupational therapists).Of the service users, 48 % were active in self-help groups.Of the relatives, most identified as parents (55.8 %).The average time of work or personal experience with psychiatry was 17.7 years (SD = 12.2; range 0-50).The majority (58.6 %) of the participants answered the questionnaire in German, 38.3 % in French and 3.1 % in Italian.
Stakeholder groups differed significantly in terms of gender (p = .043),age (p < .001)and education (p < .001)(results not tabulated): The proportion of females were higher in relatives (76.9 %) than in MHP The distribution of the stakeholder groups within each language group was as follows: Of 263 questionnaires answered in German, 185 (70.3 %) were returned by MHP, 50 (19 %) by relatives, and 28 (10.6 %) by users.Of 172 questionnaires answered in French, 140 (81.4%) were returned by MHP, 31 (18 %) by relatives and 1 (0.6 %) by a user.In Italian, the questionnaire was completed by 14 (100 %) MHP; other stakeholder groups were not represented.

Opinions on the term 'schizophrenia'
Table 2 displays the distributions of agree-and disagreement with adequacy and change of the name and concept of 'schizophrenia' as well as on the stigma associated with them respectively.The results of the unadjusted and adjusted logistic regression models for the associations between predictors and outcomes are equally shown.Accordingly, the results of the regression models for the different outcomes are as follows:

Adequacy of the name
Compared to MHP, users were less likely to agree to the adequacy of the name in the unadjusted model only and the French-speaking group were more likely to agree than the German-speaking group even after adjusting for other variables.

Change of the name
Compared to MHP, users were more likely to agree to a name change in the unadjusted model only and the French-speaking group were less likely to agree than the German-speaking group even after adjusting for other variables.

Adequacy of the concept
Bivariately, MHPs were more likely than others and the Frenchspeaking was more likely than the German-speaking group to agree to the adequacy of the concept schizophrenia.However, those associations disappeared after adjusting for other variables in the model.

Change of the concept
In the unadjusted model, users, compared to MHP, were more likely to agree to a change of the concept schizophrenia and the Frenchspeaking group were less likely to agree than the German-speaking group even after adjusting for other variables.

Stigma of name and concept
No associations between neither stakeholder group nor language group and the perceived stigma of concept nor the perceived stigma of the name 'schizophrenia' were found.
The reported adequacy of name and concept was negatively linked to the reported agreement to change name or concept respectively as well as to stigma while the latter was positively associated with an agreement to change (Table 3).

Arguments pro and con
Qualitative analysis of freetext answers revealed five main themesstigma, name, concept, history, emotions and relationship (more detail about how these themes emerged in the coding process is provided in the supplemental material).All themes apart from the last contain both arguments for retaining (pro) as well as arguments for rejecting (contra) 'schizophrenia' (see Table 4).
All arguments were found both in the German and French subsample.In the Italian subsample, only two participants gave freetext answers producing four arguments against and one argument for retaining 'schizophrenia'.In the following, we elaborate on the themes 'stigma' and 'name': Whilst many participants stated stigma as an argument against 'schizophrenia', others suggested there should be information campaigns and the term should be used precisely to fight the stigma associated with it.A family member wrote3 : "The more the word is integrated, the more it loses its taboo, like for example AIDS." Regarding the name, some argued the literal meaning of 'schizophrenia' captures the essence of the illness stating that in 'schizophrenia' "the mind is split".A psychologist elaborated: "I have personally found the word's history ("split soul" or "two souls in the chest") very helpful in psychoeducation; the psychotic perception of the person affected alone versus the shared perception of all non-affected persons around him or her." A user argued to the contrary: "My soul is not split nor broken in any other way.The name leads to misunderstanding and is often confused with multiple personality or 'split personality'." A further argument against the name was its lacking transparency, i. e. the impossibility to understand its meaning from looking at the word alone.As another family member put it: "Because normal people do not immediately understand what kind of illness it is." Finally, participants arguing that re-namings are always inefficient provided some general reflection on the nature of terms like a family member stating "the name is necessary a reduction" as well as about the relation between names and stigma e.g.a. psychiatrist who wrote "in the end, any term is what one makes of it.Even if it were only numbers, at some point the number 3.7 would be more discriminating than the number 7.2 (or others)".

Summary and interpretation of results
Our mixed-methods online survey inquired Swiss stakeholders' opinions on adequacy, change, and stigma of schizophrenia, name, and concept, and gathered arguments for and against the term.Overall, 449 mental health professionals (MHP), relatives, and users from the three main linguistic regions of Switzerland participated in the survey.The majority of the sample thought of the name and the concept as adequate, but almost half were in favor of a name change and four out of 10 favored a change of the diagnostic concept.Further, almost the entire sample rated the stigma of both the name (96 %) and the concept (90 %) as high.Name and concept were thus evaluated differently with the name being seen as more problematic than the concept.In bivariate correlations, preference for change of name and preference for change of concept were associated with low ratings of adequacy and higher ratings of stigma of name and concept, respectively.The most notable difference was between linguistic regions: Participants from the Germanspeaking part of Switzerland thought of name and concept as less adequate and were more likely to favor a change of name and concept than participants from the French-speaking part of Switzerland even after adjusting for covariates.Regarding stigma, no significant difference between stakeholder-nor between language groups was found.
The arguments reported for and against name and concept were manifold and the same topic was elaborated as a pro-argument by some, as a contra-argument by others.This suggests that opinions on schizophrenia are importantly influenced by personal experience and values.The difference between the linguistic regions that we found in the statistical analysis of the closed answers could not be found in the freetext answers.
Comparing these results to the literature, Switzerland displays a more conservative attitude towards re-naming than Italy (Lasalvia et al., 2021) and the U.S.A. (Mesholam-Gately et al., 2021), but the overall Swiss attitude is comparable to the one found transnationally by Roelandt et al. (Roelandt et al., 2020).This finding stresses the role of cultural difference in the debate, although it must be considered that Lasalvia et al.'s and Mesholam-Gately et al.'s studies explicitly framed the question of name change as a question about ways to reduce stigma which might have led to higher rates of agreement.Differences between Swiss linguistic regions have been found with regards to other healthrelated topics like organ donation and backpain (Schulz et al., 2006;Schulz et al., 2013;Dunkel et al., 2018) supporting the idea that the difference found between the German-and the French-speaking region in our study might indeed be linked to their specific microcultures.
Regarding the arguments revealed by the thematic analysis of freetext answers, most of them have been described before, most  prominently perhaps the argument put forward by members of all stakeholder groups alike that the stigma associated with schizophrenia is harmful (Asylum Magazine, 2017;Dillon, 2007;Voice America, 2012;Schizophrenia Inquiry, 2012;Lasalvia et al., 2021;Mesholam-Gately et al., 2021;Sartorius et al., 2014), and the argument that the concept is scientifically invalid (Guloksuz and van Os, 2019;Bentall, 2003;Van Os, 2010;Guloksuz and van Os, 2018).The literal, Greek meaning of 'schizophrenia' has also often been mentioned as a contra-argument as it is considered to increase stigma and lead to the confusion of schizophrenia with dissociative identity disorder (Borsche et al., 2007;Holzinger et al., 1998;Sulzenbacher et al., 2002).Participants of our study mentioned these arguments but evaluated them in new and more nuanced ways: The association of 'schizophrenia' with a split mind was, by some, seen as helpful in explaining the symptoms.Most interestingly perhaps, stigma which has up-to-now rather unanimously been portrayed as the main reason for a name change was also mentioned as an argument for retaining 'schizophrenia': Some participants pointed out the possibility to reclaim (Brontsema, 2004;Galinsky et al., 2003) the term, i.e. to revalue it by users self-consciously referring to themselves in terms of this label.All arguments were produced by participants from the German-and the French-speaking group.The same groups however displayed different opinions on name change and change of concept.The triangulation of quantitative and qualitative results thus suggests that whilst the arguments available in the discourse on 'schizophrenia' are comparable across cultural regions, the attitude towards re-naming and changing the diagnostic concept are subject to cultural difference.
Taken together, the differences in the attitude towards re-naming schizophrenia found within our survey and across surveys conducted in different global regions point to the importance of local factors.Herein, the role of culture and language can of course not be told apart.However, it is worthwhile considering the relation between name and concept in light of their relation to culture and language respectively.The name, i.e. the linguistic sign or simply the sequence of letters/ sounds, cannot be the same globally, but has to be translated into different languages.The name's morphological and grammatical properties are thus different in different languages, and these properties have an impact on how it is used.This is especially important because diagnostic terms like 'schizophrenia' inevitably behave like ordinary linguistic expressions and us such travel across discourse spheres, i.e. they can and will be used in different cultural and communicative contexts than the original clinical one (Maatz and Ilg, 2021).If a term's meaning is its use in language (Wittgenstein, 1958), the concept does not remain unaffected if the patterns of use change.Patterns of use of course do not only depend on linguistic properties but are also culture-bound, the media discourse playing an especially important role in shaping and disseminating such patterns.This has been shown for 'schizophrenia' in various countries and languages (Athanasopoulou and Sakellari, 2016;Athanasopoulou and Välimäki, 2014;Cain et al., 2014;Dubugras et al., 2011;Goulden et al., 2011;Kara and Kara, 2022;Park et al., 2012;Thys et al., 2013;Wahl et al., 1995), also in Switzerland (Hoffmann-Richter, 2000;Ilg, 2019), but the media discourse in the three Swiss linguistic regions has not been systematically compared in this respect yet.
Taken together, in line with our findings, these insights highlight schizophrenia's nature as not only a scientific, but also a linguistic and cultural object (Woods, 2011).Whilst our specific results are thus not generalizable beyond Switzerland, the generalizable point our findings support is the importance of taking into account local factors in the global debate.

Strengths and limitations
This is the first study inquiring attitudes on schizophrenia in Switzerland.Given that it was conducted in the three main linguistic regions of the country and that previous surveys never employed exactly the same design, it is also the first study that allows a direct comparison between different linguistic and cultural regions.Regarding design, our study distinguished between name and concept.Whilst conceptually a strength, this might have been a pragmatic limitation because it presupposed participants' willingness and ability to engage with this unfamiliar distinction.Importantly also, our survey included the option to give freetext answers for each closed question.This allowed to study the arguments underlying the expressed opinions and to capture ambivalent reflections which necessarily get lost in closed answers.Regarding the sample, an obvious limitation is that it was not representative.Generally, users and relatives were underrepresented with all users apart from one coming from the German-speaking region, and relatives only from the French-and German-speaking regions.Further studies should seek to include a higher proportion of these stakeholder groups across language groups to give persons with lived experience of 'schizophrenia' a stronger voice in the debate.Despite the overall small number of participants of the Italian-speaking region, their proportion of the overall sample is similar to their proportion of the overall Swiss population (8 %) and was therefore not unexpected.As the results in the Italianspeaking sub-sample, although similar to those of the French-speaking sub-sample, did not reach significance as an artifact of sample size, further studies with larger samples are required to confirm our results.The fact that, in contrast to previous surveys in other countries, we included MPH other than psychiatrists is a strength because the MHP subsample thus better represents the variety of healthcare personnel which is relevant for the use of 'schizophrenia' in the clinical discourse sphere.

Conclusions
Schizophrenia, both name and concept, have always been and remain disputed, the critical discourse displaying greatly heterogenous arguments.Opinions on whether name and/or concept should be changed depend on experiential background, global region and probably a great number of other factors that remain to be investigated in more detail.This discursive constellation demonstrates that schizophrenia is not treated as a mere scientific object, but perhaps even predominantly as a cultural oneconsidering that psychiatric practice incl.scientific inquiry is equally culturally embedded.Moreover, the attitude towards re-naming itself appears, as our study suggests, to be a matter of culture and/or language.The re-naming debate is not a waste of words we believe.Surveys however should not be considered a means to arbitrating about whether to re-name 'schizophrenia'.Rather, they can be seen as part of the muchneeded debate about some "big questions" of psychiatry like: (How) can we find a way to communicate reliably about mental illness whilst at the same time accommodating its essential subjectivity and cultural difference?How can we as societies and individuals conceive of and respond to mental suffering in a non-stigmatizing way?How can perspectives from other disciplines e.g.philosophy, linguistics, sociology, and anthropology be made fruitful in such debates?If these background questions are considered, the re-naming debate should go on.
a Only relates to the subsample of MHP.bOnly relates to the subsample of relatives.cOnlyrelates to the subsample of users.A. Landolt et al.(

Table 2
Opinions on the term.

Table 3
Point-biserial correlations between outcomes on opinions.

Table 4
Arguments pro and con.