The role of metaphor and metonymy in the portrayal of what is currently called schizophrenia

53
The role of metaphor and metonymy in the portrayal of what
is currently called schizophrenia
Helga Mannsåker, University of Bergen (helga.mannsaker@uib.no)
Abstract
This paper employs cognitive linguistics to investigate the role of metaphor and metonymy in
the portrayal of schizophrenia in Scandinavian psychiatric textbooks from three time periods:
c. 1900, when the name of the disorder was dementia praecox (‘prematurely out of one’s mind’),
c. 1950, when schizophrenia (‘split mind’) had replaced dementia praecox, and c. 2000. The study
reveals that metaphor and metonymy play important roles in the naming and descriptions of
the disorder. The change of name seems to have led to a change in metaphor use in the
textbooks, with patients being described as “split” after the introduction of schizophrenia. The
adjective schizophrenic makes it possible to refer to the diagnosed person by means of the
diagnosis, as in “a schizophrenic”. Both the connotations of schizophrenia and the DIAGNOSIS
FOR DIAGNOSED-metonymy are likely to contribute to the stigmatisation associated with the
illness and the persons suffering from it.
Die Studie untersucht mithilfe kognitionslinguistischer Methoden die Rollen von Metapher
und Metonymie bei der Darstellung von Schizophrenie in skandinavischen psychiatrischen
Lehrbüchern aus drei Zeiträumen: ca. 1900, als der Name der Krankheit noch Dementia praecox
(‘vorzeitige Demenz‘) war, ca. 1950, als Schizophrenie (‘gespaltene Seele‘) den Terminus
Dementia praecox ersetzt hatte, und ca. 2000. Die Studie zeigt, dass Metapher und Metonymie
sowohl bei der Namensgebung als auch bei der Beschreibung der Krankheit wichtige Rollen
spielen. Die Namensänderung scheint zu einer Änderung der Verwendung von Metaphern in
den Lehrbüchern geführt zu haben, wobei Patienten nach Einführung des Begriffs
‘Schizophrenie’ als „gespalten“ beschrieben wurden. Das Adjektiv schizophren ermöglicht es,
mittels der Diagnose auf die diagnostizierte Person Bezug zu nehmen, wie in „der/die
Schizophrene“. Sowohl die Konnotationen der Schizophrenie als auch die DIAGNOSE FÜR
DIAGNOSTIZIERT(E)-Metonymie dürften zur Stigmatisierung der Krankheit und der darunter
leidenden Personen beitragen.
1. Introduction
How do we name and describe phenomena that we do not understand and are
unable to observe directly? This question is of particular relevance in
psychiatry, which is a medical speciality whose research object (i.e., mental
disorders) is not available for direct observation. There are no specific
neurobiological markers or objective measuring methods in psychiatry – not
even for severe mental disorders such as schizophrenia. Psychiatry is dealing
with abstract, subjective, and changeable phenomena that can only be indirectly
observed and measured, via interpretation and assessment of signs or
symptoms: behaviour or self-reported subjective experiences. Language is a
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central tool in psychiatry. It is used for diagnosing (“the psychiatric interview”),
for therapy (“talk therapy”), for evaluating treatment (medical records) as well
as for defining and describing psychiatric disorders scientifically. A psychiatric
diagnostic term like schizophrenia is a form of label (Zola 1993). It affects the
diagnosed person (Lauveng 2005: 193-5), and it is difficult to remove it, as it
tends to stick to the person with “superglue” (Malt et al. 2003: 51). However,
little is known about the causes and developmental processes of mental
disorders, and there is constant debate concerning their definition and
categorisation.
One of the principles of medical nomenclature is that the names of illnesses
should ideally shed light on their nature. But illnesses whose nature is still
largely unknown also need names and scientific descriptions, and in such cases,
metaphor and metonymy often play important and theory-building roles (Boyd
1979; Leary 1990; Temmerman 2000; Sánchez et al. 2012). The naming and
renaming of a psychiatric disorder may thus affect the scientific and clinical
understanding of the disorder, but also the perception and self-perception of
the persons suffering from it, because categorisations and descriptions of
mental disorders implicitly entail categories and descriptions of human beings.
The case of what is today called schizophrenia (‘state of split mind’) demonstrates
these issues. The disorder is still somewhat of an enigma (Keshavan et al. 2011).
It is not as yet known what causes it, how to delineate the category, and how to
interpret it. Schizophrenia is also laden with strong stigmatisation as well as
self-stigmatisation (Gallo 1994; Kingdon et al. 2008), and research has shown
that the stigma is amplified by media’s portrayal of persons diagnosed with
schizophrenia (cf. Schlier/Lincoln 2014; Magliano et al. 2011; Dubugras et al.
2011b; Anda 2013; Vahabzadeh et al. 2011 on German, Italian, Brazilian,
Norwegian and U.S. newspapers respectively). Similar depictions are produced
by the movie industry. Owen (2012: 655) reports that “[a] majority of characters
displayed violent behavior toward themselves or others, and nearly one-third
of violent characters engaged in homicidal behavior”. This unbalanced
portrayal may cause society to fear and distrust persons with schizophrenia and
also cause persons with schizophrenia to fear and distrust themselves (Nath
2013).
Moreover, the etymology of the term schizophrenia seems to have affected the
public conception of the disorder (cf. Luty et al. 2006; Schomerus et al. 2007).
Mannsåker: Metaphor and metonymy in the portrayal of schizophrenia
55
The association between schizophrenia and split personality is likely to combine
with the media-enhanced association between schizophrenia and violence and
create a public image equivalent to a Jekyll/Hyde-personality (Mannsåker
2020), and this misconception appears to be nearly as old as the scientific term
itself (McNally 2007).
Furthermore, there is currently a discussion in psychiatry of whether to replace
schizophrenia with a new and (hopefully) less stigmatised (and stigmatising)
name (Lasalvia et al. 2015; George/Klijn 2013; Guloksuz/van Os 2018, 2019),
but with the exception of some Asian countries where the name has been
changed1, there seems to be a lack of agreement in psychiatry concerning both
whether a name change is in fact (now) necessary, and if so, what the
replacement name should be.
Historically seen, the term schizophrenia was introduced at a meeting of the
German Psychiatric Association in 1908 by the Swiss psychiatrist Eugen Bleuler
as a replacement name for the German psychiatrist Emil Kraepelin’s term
dementia praecox (‘prematurely out of one’s mind’). Bleuler stated one semantic
and one morphological argument for replacing dementia praecox with
schizophrenia: The term dementia praecox was in his view doubly misleading: “Im
Interesse der Diskussion möchte ich nochmals hervorheben, daß es sich bei der
Kräpelinschen Dementia praecox weder um eine notwendige Dementia, noch
um eine notwendige Praecocitas handelt.“ ‘For the sake of the discussion I will
once again stress that the Kraepelinian dementia praecox does not inevitably
involve a dementia, nor a praecositas’ (1908: 436). And dementia praecox did not
lend itself well to word formation (ibid.).
By c. 1950, the metaphoric term schizophrenia, accompanied by the derived2
adjective schizophrenic, had replaced the metaphoric term dementia praecox in
1 According to Lasalvia et al. (2015) the following name changes have taken place in Asia in
the period 2002–2012: South-Korea: jungshinbunyeolbyung (‘mind-split disease’) has been
replaced with johyeonbyung (‘attunement disorder’); Japan: seishin-bunretsu-byo (‘mind-splitdisease’)
has been replaced with togo-shitcho-sho (‘integration disorder’); Hongkong: jingsheng-
fen-lie-zheng (‘mind-split-disease’) has been replaced with si-jue-shi-tiao (‘dysregulation
of thought and perception’);Taiwan: jing-sheng-fen-lie-zheng (‘mind-split-disease’) has been
replaced with sī-jué-shī-tiáo-zhèng (‘dysfunction of thought and perception’).
2 The derivation schizophren from Schizophrenie was most likely made by analogy with the
already existing term set Hebephrenie – hebephren.
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psychiatry (Noll 2011: 262). What were the consequences of the name switch
and the adjectival word formation for the scientific descriptions of the diagnosis
and of the diagnosed?
While there has been some research on the use of metaphors in the language of
psychiatry (see for example the “MOMENT”3 project) and Agdestein-Wagner
(2014), relatively few have analysed the names of psychiatric diagnoses and the
linguistic consequences of name changes. To my knowledge, no research has
been made concerning the role of metonymy in the language of psychiatry. Noll
(2011), Berrios et al. (2003) and McNally (2007, 2012, 2016) are among those who
have investigated the diagnostic concepts of dementia praecox versus
schizophrenia. Researchers carrying out this research are typically psychologists,
psychiatrists, and historians of medicine, not linguists, and the research
material consists of writings of leading psychiatrists in the international history
of psychiatry.
Due to this gap in research, I have investigated the role of both metaphor and
metonymy in the scientific naming and description of what is currently called
schizophrenia.4 I argue that in addition to being metaphoric, the terms dementia
praecox and schizophrenia are also metonymic. The two terms frame the disorder
– and the disordered – differently.
To find out what linguistic consequences the name change has had for the
description of the phenomenon, I have examined Scandinavian psychiatric
textbooks for medical students diachronically with the following two research
questions:
1. Did the change of name from dementia praecox to schizophrenia lead to any
changes in source domains (Lakoff/Johnson 1980) used for describing the
diagnosis and the diagnosed?
2. What – if any – metonymic role(s) do the noun schizophrenia and the
according to Bleuler much needed adjective schizophrenic play in the
description of the diagnosis and the diagnosed?
3 MOMENT PROJECT: Metaphors of severe mental disorders is a multidisciplinary research
project using Conceptual Metaphor Theory to analyse the discourse of people with a mental
health diagnosis and mental health professionals (https://mentalhealthmetaphors.uoc.edu/).
4 The investigation is part of my doctoral thesis (Mannsåker 2017).
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I chose to investigate textbooks because they are read by an expert audience, the
most important group being medical students. Textbooks gather the most
central and established knowledge concerning a scientific topic, including the
terminology. They are thus a source of ‘common ground’ and set language
practises within a discipline. Their authors use the terms and categorisations
that have been firmly established in the discipline, thus contributing to their
further entrenchment. One of their purposes is to socialise students into a
scientific discipline. They provide instructions to the students on how to
categorise the phenomena in question, and how to describe them. Psychiatric
textbooks thus teach medical students how to talk as well as think about
psychiatric phenomena and psychiatric patients. Furthermore, they also teach
the students how to approach, diagnose and treat the patients. The textbooks
may therefore have a significant impact on both the medical students and their
future patients.
2. Schizophrenia
There are large variations both diachronically and synchronically in the
conception of schizophrenia. According to Parnas et al. (2009: 247), over 20
different operational definitions have been proposed for schizophrenia during
the last 30 years. In the psychiatric literature schizophrenia has been described
in many ways: as several different conditions, a disorder with subgroups, a
group of disorders, a syndrome, several syndromes, a spectrum, as one of the
poles in a psychosis-continuum with bipolar disorder as the other pole, and,
more generally, as part of a continuum with normality as one pole and
psychosis as the other (van Os 2009: 365), as a gestalt (Parnas 2011), as nonexisting
(Szasz 1976), as an illness and a way of life (Kringlen 1997: 39) and as a
form of severe affective disorder (Lake 2012). The term schizophrenia has
denoted very different phenomena and has also had very different extensions
in different countries and different clinical institutions (Kendell 1975), but
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recent revisions of the two diagnostic manuals DSM5 and ICD6 have improved
the situation (Malt et al. 1993: 195).
Currently and according to ICD-117 schizophrenia is a group of mental
disorders characterised by disturbances in thinking, perception, self-experience,
cognition, volition, affect and behaviour (WHO 2018). There seems to be
consensus in current psychiatry that the causes are multiple and complex, and
that schizophrenia is an umbrella term for several different disorders or
conditions. According to Tandon et al. (2009), a full understanding of the
phenomenon requires dimensional rather than categorical thinking, which may
be too complex to do in real life (Parnas et al. 2009: 36). Schizophrenia has no
cardinal symptom8 nor a pathognomonic symptom9. Naming this kind of
phenomenon often requires both metonymy and metaphor, and in what follows
I will discuss the metonymic and metaphoric aspects of the terms dementia
praecox and schizophrenia respectively.
3. Metaphor and metonymy in the naming of schizophrenia
According to Langacker (1999: 198–201) “a well-chosen metonymic expression
lets us mention one entity that is salient and easily coded, and thereby evoke –
essentially automatically – a target that is either of lesser interest or harder to
name”. According to Conceptual Metaphor Theory (Lakoff/Johnson 1980, 1999)
we use metaphor as a cognitive device to conceptualise abstract, complex, and
unknown phenomena by means of more concrete, simple and well-known
phenomena.
Barcelona (2011: 52) defines (conceptual) metonymy as an asymmetric mapping
of a source onto a target. The source and the target are conceptual domains
within the same functional domain, and they are linked by a pragmatic function,
thus making it possible for the source to mentally activate the target.
5 Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric
Association.
6 International Statistical Classification of Diseases and Related Health Problems, published by the
World Health Organization.
7 ICD-11 is the eleventh edition of WHO’s International Classification of Diseases.
8 Cardinal symptom: ‘main symptom’.
9 Pathognomonic symptom: ‘symptom specific for one disease’.
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(Conceptual) metaphor is defined by Lakoff (21993) as a mapping between
corresponding aspects from a target domain and a source domain. The mapping
projects knowledge about aspects of the source domain on to knowledge about
corresponding aspects of the target domain, thus enabling us to utilise our
knowledge of the source domain to conceptualise the target domain. The source
domain frames the target domain in a specific way, highlighting aspects of the
target domain that correspond with aspects of the source domain while at the
same time hiding aspects of the target domain that do not correspond with
aspects of the source domain. Metaphor and metonymy often interact, mainly
in the form of metaphoric expressions containing metonymies, or metaphor
from metonymy (Goossens 2009), or metonymy-based metaphor (Deignan
2005).
4. The metonymic aspect of dementia praecox and schizophrenia
The phenomenon that is currently referred to by the term schizophrenia, was first
defined by Kraepelin as a diagnostic category in the fifth edition of his textbook
Psychiatrie by the name of Dementia praecox (Kraepelin 1896). In the eight edition
Kraepelin explains the choice of name for the category:
I got the starting point of the line of thought which in 1896 led to
dementia præcox being regarded as a distinct disease on the one hand
from the overpowering impression of the states of dementia quite
similar to each other which developed from the most varied initial
clinical symptoms, on the other hand from the experience connected
with the observations of Hecker that these peculiar dementias seemed
to stand in near relation to the period of youth. As there was no
clinical recognition of it, the first thing to be done for the preliminary
marking off of the newly circumscribed territory, was to choose a
name which could express both these points of view. The name
“dementia præcox”, which had already been used by Morel and later
by Pick (1891), seemed to me to answer this purpose sufficiently, till a
profounder understanding would provide an appropriate name
(Kraepelin/Barclay, [1909]1919: 3-4).
In the 1899 sixth edition of Psychiatrie Kraepelin included the former separate
conditions catatonia, hebephrenia (which in the fifth edition corresponds to
dementia praecox) and dementia paranoides in the category dementia praecox,
because he believed that they all had the same outcome.
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The term dementia praecox refers to the prognosis/outcome of the disorder(s),
and the term may be analysed as an EFFECT FOR CAUSE-metonymy, where an
effect (premature dementia) refers to the cause: the disorder(s) causing the
premature dementia. Alternatively, it may be analysed as a PART FOR WHOLEmetonymy,
as a disorder may be mentally represented as a conceptual domain
consisting of the following elements: CAUSE(S), ONSET, SYMPTOMS, COURSE,
OUTCOME, PATIENT.
Dementia was originally a term referring to a wide range of conditions of
psychosocial deficits, but from the end of the 19th century and onwards it was
reserved for an ailment associated with elderly people, hence the reason for the
modifier ‘praecox’ (Berrios et al. 2003). Dementia praecox had a Scandinavian
synonym, ungdomssløvsinn10, which literally means ‘youth-blunt-mind(edness)’.
Sløvsinn is an archaic Scandinavian term for different forms of dementia.
Ungdomssløvsinn (‘youth dementia’) is based on the same EFFECT FOR CAUSE- or
PART FOR WHOLE-metonymic relation as dementia praecox.
A few years after Kraepelin‘s presentation of dementia praecox, Bleuler coined
and launched the replacement name schizophrenia. The term literally refers to
what Bleuler considered a cardinal symptom of the disorder: “Ich glaube
nämlich, daβ die Zerreiβung oder Spaltung der psychischen Funktionen ein
hervorragendes Symptom der ganzen Gruppe sei […].” ‘I believe that the
tearing apart or splitting of the mental functions is a distinctive symptom of the
whole group’ (Bleuler 1908: 436). It may be analysed in the same two ways as
dementia praecox: as an EFFECT FOR CAUSE-metonymy where an (assumed) effect
(the cardinal symptom of ‘splitting of the mental functions’ refers to the cause:
the underlying disorder that causes the symptom, or as a PART FOR WHOLEmetonymy,
where the cardinal symptom stands for the whole disorder.
Metonymy is an important tool for naming disorders, enabling one salient
and/or directly observable aspect of the disorder to refer to the whole disorder.
10 More precisely, the Danish form is ungdomssløvsind, the Norwegian form is
ungdomssløvsinn, and the Swedish form is ungdomsslösinne. The Norwegian form is used in this
article.
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5. The metaphoric aspect of dementia praecox and schizophrenia
The term dementia praecox consists of the two Latin words dementia and praecox.
Dementia consists of Latin de ‘off, from’ and Latin mens ‘mind’ and the suffix -ia,
which in medical terminology means ‘condition/state’, and the Latin meaning
is ‘state of derangement of the mind, madness, insanity’ (Glare 1982). Dementia
is derived from the Latin adjective demens, which means ‘out of one’s mind,
mad, frenzied, insane’ (ibid.). Praecox (‘before time, prematurely’) comes from
Latin prae ‘before’ and Latin coquere ‘to cook, ripen’ (ibid.). Dementia praecox
literary means ‘state of being prematurely out of one’s mind’. The terms
demented and dementia are surface manifestations of the conceptual metaphor
THE MIND IS A PHYSICAL ENTITY, where the mind is conceptualised as a concrete
entity that can be separated from the body. The term dementia has negative
connotations, as someone who is ‘out of his mind’ as no access to his mind
anymore and is ‘mindless’
There seems to be a dual system for the metaphoric conceptualisation of
reduced mental capacity as lack of co-location between the mind and the person:
Either the person is removed from his mind (‘to be out of one’s mind’), or the
mind is removed from the person (‘to lose one’s mind’). The mind can thus be
conceptualised as a stationary entity or a location, or as a (re)movable object.
The Scandinavian term sløvsinn is a metaphoric expression where the mind is
portrayed as a physical object with the property of being blunt. The adjective
sløv is commonly defined as ‘unsharp’, often illustrated with the example sløv
kniv (‘blunt knife’). Figurative senses of the word are ‘weak, weakened,
sluggish, lazy, indifferent’. The basic meaning of sløv is ‘not sharp’, and the
word has negative connotations. It describes objects that are supposed be sharp
but are not (anymore). A person who has lost her ‘sharpness’ and developed a
‘blunt mind’, could be said to have lost her functionality due to weakened
motivation, attention, and emotion. The metaphor is also present in ICD-11’s
description of schizophrenia, where “blunted emotional expression” serves as
an example of disturbances in affect (WHO 2018).
The term schizophrenia (German Schizophrenie) is a word formation containing
two Greek elements: skhizein ‘split’ and phren ‘mind’, plus the suffix -ia.11
11 Schizo- is the combining form of skhizein. Latin -ia has the form -ie in German and -i in
Scandinavian.
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Schizophrenia thus literally means ‘state of split mind’, and like sløvsinn it is a
metaphoric expression where the mind is portrayed as an object with physical
properties. That something is split entails that what was once whole, is now
divided in separate parts, and this will normally disrupt or ruin the functioning
of the object. Bleuler’s term is one of many manifestations of what Berrios et al.
(2003) call “The Splitting Metaphor”. This metaphor originated early in the 19th
century as an explanatory model for deviant behaviour:
[…] the metaphor of separating, dividing, breaking, dissociation,
divorcing or splitting of mental functions became popular to explain
unpredictable and strange human behaviour. The metaphor was used
in popular literature and folk and scientific psychology (ibid.: 119).
Schizophrenia and schizophrenic are now firmly established in many languages as
colloquial metaphors for various forms of ‘inner splits’ (Joseph et al. 2015;
Finzen et al. 2001; Boke et al. 2007; Magliano et al. 2011; Dubugras et al. 2011a;
Park et al. 2012; Athanasopoulou/Välimäki 2014; Mannsåker 2020; Thys et al.
2013).
The terms dementia praecox, schizophrenia and ungdomssløvsinn are neither
examples of metonymy in metaphor nor metaphor from metonymy or
metonymy-based metaphor. If anything, they could perhaps be examples of
Goossens’ (2009: 366) category Metaphor within metonymy, of which he found
only one example in his research material, as dementia praecox, schizophrenia and
ungdomssløvsinn are metaphoric expressions that are used as EFFECT FOR CAUSEor
PART FOR WHOLE-metonymies.
6. Method
I have investigated excerpts from various Scandinavian psychiatric textbooks to
find answers to the research questions: Did the change of name from dementia
praecox to schizophrenia lead to any changes in source domains used for describing
the diagnosis and the diagnosed? and What – if any – metonymic role(s) do the noun
schizophrenia and the adjective schizophrenic play in the descriptions of the
diagnosis and the diagnosed? The first question entails an investigation of source
domains related to the description of the diagnosis and the diagnosed, the
second entails an investigation of the usage(s) of the terms schizophrenia and
schizophrenic.
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My research material consists of excerpts regarding the disorder from nine
Scandinavian (i.e., Norwegian, Swedish and Danish) textbooks on psychiatry
from three time periods: c. 1900, when the name of the disorder was dementia
praecox/ungdomssløvsinn, c. 1950, when schizophrenia had fully replaced dementia
praecox/ungdomssløvsinn, and the period after 2000, i.e., textbooks that are
currently or recently used in Scandinavian medical schools. The textbooks are
all written in a Scandinavian language by Scandinavian authors for a
Scandinavian market.
The excerpts are collected from the following textbooks:
 1900:
o Holm (1895: 33, 104–118, 184, 294): Den specielle psychiatri for læger
og studerende: forelæsninger holdte ved Kristiania universitet 1895 med
sygehistorier, facsimiler af haandskrifter samt tegninger
o Friedenreich (1901/2009: 89–108): Kortfattet, speciel Psykiatri
o Vogt (1905: 117–143): Psykiatriens grundtræk
o The excerpts are in total 64 pages long and contain 17 414 words.
Holm and Vogt are Norwegian, Friedenreich is Danish.
 1950:
o Langfeldt (1951: 341–395): Lærebok i klinisk psykiatri
o Smith/Strömgren (1956: 133–160): Psykiatri
o Lundquist (1959: 174–184): Psykiatri och mentalhygien
o The excerpts are in total 91 pages long and contain 38 017 words.
Langfeldt is Norwegian, Smith/Strömgren Danish and Lundquist
Swedish.
 2000:
o Cullberg (2003: 267–302): Dynamisk psykiatri
o Malt/Retterstøl/Dahl (2003: 193–236): Lærebok i psykiatri
o Parnas/Kragh-Sørensen/Mors (2009: 247–343): Klinisk psykiatri
o The excerpts are in total 171 pages long and contain 73 536 words.
Cullberg is Swedish, Malt et al. Norwegian and Parnas et al.
Danish.
Textbooks are often published in many editions through long periods, so to
obtain different authors and textbooks for each period, I decided to have a time
interval of 50 years. I chose to include textbooks from all the Scandinavian
countries to increase my research material. There are few Scandinavian
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textbooks from the 1900 and 1950 period.12 As several of the textbooks are
written by a single author, there could potentially be linguistic idiosyncrasies in
the texts. The inclusion of three textbooks from each period reduces this effect.
The languages and cultures of the three Scandinavian countries are in many
ways very similar. The textbooks are used across the borders. Dahl, who is one
of the authors of Malt et al. (2003), is also the author of one of the chapters in
Parnas et al. (2009). This indicates that Scandinavian psychiatric textbooks
present compatible portrayals of the psychiatric discipline. The aim of the
investigation is therefore not to compare the different languages, but the
different time periods. I have however compared the Scandinavian textbooks
with Bleuler (1908) in respect of metonymic uses of schizophrenia and
schizophrenic to find out how much the latter has influenced the former. German
psychiatry had a significant impact from the 1850s onward. It was common for
leading Scandinavian psychiatrists to have academic stays in Germany, and
German was an important language of science in Scandinavia. Furthermore, the
Scandinavian languages are closely related to German and have similar patterns
of word formation and inflection.
7. Data analysis
I wrote the different excerpts from the nine textbooks into Excel sheets, sentence
by sentence, creating search- and filterable files. The excerpts constitute a mini
corpus consisting of three sub corpora (1900, 1950 and 2000) containing a total
of 128 960 words. Due to the relatively small size of the corpus, it is not possible
to draw firm conclusions. On the other hand, the size of the corpus enables close
reading and thus a more fine-grained analysis, making it possible to discover
nuances and phenomena that are more difficult to identify in larger corpora.
Bleuler’s 1908 article was investigated manually via close reading of a paper
copy.
I have translated quotes and examples from both the textbooks and the article
into English and put the translations in single quotation marks. Relevant
structures are highlighted in bold and italics, both in the original quotes and in
the translations.
12 I was not able to find a Swedish textbook from the 1900 period, and the Swedish textbook
from the 1950 period is an elementary introduction to psychiatry.
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8. Findings
8.1 Changes in source domains used for describing the diagnosis and
the diagnosed
According to Lakoff (1987) a conceptual metaphor is cognitively alive if its
mappings produce metaphoric expressions. If schizophrenia is described using
Scandinavian words with the basic meaning ‘splitting’ or the like in the
Scandinavian textbooks, it could indicate that “The Splitting Metaphor” is alive
in the field. If the textbooks from 1950 and 2000 contain such linguistic surface
manifestations of the metaphor, a comparison with the textbooks from 1900
could provide indications as to whether these metaphors first emerged after the
introduction of the term schizophrenia in 1908 or were present to the same extent
in the textbooks pre-1908. If they appear to have emerged together with
schizophrenia, the name change could be said to have entailed a shift in choice of
linguistic metaphors to describe the phenomenon, which may indicate a new
metaphoric conceptualisation of the phenomenon, leading to new research
questions and problem-solving strategies (Thibodeau/Boroditsky 2011; Leary
1990; Schön 1979) and a new conception of the patients, especially if linguistic
metaphors related to the term ungdomssløvsinn are present in the corpus but
more frequent in the textbooks from 1900 compared to those from 1950 and
2000.
I choose to investigate the frequency and distribution of the following
Scandinavian stems13, which all appear in the corpus of excerpts and could be
said to more or less relate to either the source domain BLUNTNESS
(ungdomssløvsinn) or the source domain SPLITTING (schizophrenia):
 BLUNTNESS: sløv- (‘blunt’), avstump- (‘made blunt’), -flat- (‘flat’).
 SPLITTING: splitt- (‘split’), spalt- (‘split’), kløyv- (‘cleave’), dissosi-
(‘dissoci-‘), fragment- (‘fragment-‘), oppløys- (‘dissolve‘), (u)samanheng-
(‘(lack of) coherence’).
The list of stems includes loan stems and loan word formations with a more
concrete basic meaning in Scandinavian. I have included the stems fragmentand
oppløys-, which connote a more extensive break-up than splitting, thus
possibly being more in tune with the connotations of Zerreißung (‘the tearing
13 For the sake of word economy only the Norwegian (nynorsk) versions of the stems are
presented here.
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apart’), as used by Bleuler (1908: 436). The stem (u)samanheng-, which connotes
a looser former connection between the now separated parts, is also included.
The stem flat- is included to compare the frequency and distribution of the
BLUNT-metaphors, which have negative connotations, with the more neutral
FLAT-metaphors, which are often used to describe a lack of emotional
expression in psychiatry.
I did not include the stems dementia and praecox, as the linguistic manifestations
of the conceptual metaphor by which dementia is motivated normally would be
multiword expressions and clauses and thus more difficult to search for in the
corpus. Also, the literal meaning of dementia is not mentioned in the textbooks.
The opposite is true for schizophrenia. In all the textbooks from the 1950 and 2000
the literal meaning of the term schizophrenia is in fact explicitly presented. This
may be a pedagogic strategy for creating or strengthening the reader’s
metaphoric associations and images, so that the abstract and complex
phenomena presented in the text become more understandable. It may also
indicate that the authors themselves at least partly base their understanding of
schizophrenia on “The Splitting Metaphor”. It is a point worth noting that none
of the authors problematize or criticise the metaphor on which the term
schizophrenia is based. As a result, the association between schizophrenia and
‘mental splitting’ is established in the textbooks.
To investigate the frequency and distribution of the chosen stems I searched for
each of them in the corpus of excerpts and based on the textual context of each
token I decided if the token was relevant or not. All instances of overflatisk
(‘superficial’) are for example irrelevant for the stem -flat-, as they do not
describe the disorder or the patient.
The results of the search and exclusion process are listed in Table 1 in number
of instances (N) and the frequency relative to the total number of words in each
of the sub corpora (in per mille).
Mannsåker: Metaphor and metonymy in the portrayal of schizophrenia
67
Stem 1900 sub corpus 1950 sub corpus 2000 sub corpus
N ‰ N ‰ N ‰
sløv- 31 1,78 21 0,55 6 0,08
avstump- 1 0,06 17 0,45 2 0,03
-flat- 0 0,00 6 0,16 14 0,19
In total: 32 1,84 44 1,16 22 0,30
splitt- 0 0,00 5 0,13 11 0,15
spalt- 0 0,00 22 0,58 4 0,05
kløyv- 0 0,00 1 0,03 2 0,03
In total: 0 0,00 28 0,74 17 0,23
dissosi- 2 0,11 1 0,03 9 0,12
fragment- 0 0,00 0 0,00 5 0,07
oppløys- 1 0,06 8 0,21 16 0,22
(u)samanheng- 16 0,92 10 0,26 34 0,46
In total: 19 1,09 19 0,50 64 0,87
Table 1: Metaphoric stems associated with BLUNTNESS and SPLITTING
Table 1 shows that Scandinavian stems related to BLUNTNESS and SPLITTING are
in fact used to describe the diagnosis and the diagnosed. The metaphoric terms
ungdomssløvsinn and schizophrenia are surrounded by metaphoric expressions
motivated by the same conceptual metaphor. The conceptual metaphors are
cognitively alive. The transition from dementia praecox to schizophrenia that
occurred from 1908 to c. 1950 appears to have entailed a transition from
bluntness-metaphors to splitting-metaphors in the textbooks. The use of sløvhas
diminished markedly since 1900, while the numbers for avstump- and -flatare
more inconclusive. The authors generally use sløv- to describe the state of
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dementia and the overall demeanour of the patient and avstump- and -flat- to
describe the patient’s (apparent) lack of emotion.
The most notable of the findings is that the stems splitt-, spalt-, kløyv- and
fragment- are not found in the 1900 textbooks at all, and that they are indeed
found in both the 1950 and the 2000 textbooks. In other words, Scandinavian
expressions connected to the source domain SPLITTING are used in the textbooks
to describe the diagnosis and the diagnosed. They are however exclusively used
after Bleuler’s introduction of the concept of “die Zerreißung oder Spaltung der
psychischen Funktionen“ (‘the tearing apart or splitting of the mental
functions’) as a cardinal symptom of the disorder along with the terms
Schizophrenie and schizophren. The change of (metaphoric) name for the disorder
seems to have caused a change in the metaphoric descriptions of the disorder.
The relatively small numbers do not provide basis for firm conclusions.
Nevertheless, the investigation provides indications of language use, and at the
very least it answers the question of whether a stem was used at all in at least
one textbook in one of the three periods. According to Cameron et al. (2010: 129)
the size of a set of related linguistic metaphors is not always proportional to the
set’s importance. It is the discourse function of the related metaphors that
decides how powerful they are.
In this regard it is noteworthy that none of the 1900 textbooks, but all the 1950
textbooks use the Scandinavian stems split-, spalt- and/or kløyv- to define the
diagnostic category:
(1) Ordet schizofreni betyder splittrat sinne eller klyvning av själslivet
och utgör en beteckning på de viktigaste symtomen vid ifrågavarande
sjukdom. ‘The word schizophrenia means split mind or cleaving of
the mental life14 and constitute a designation of the most important
symptoms of the disorder in question’ (Lundquist 1959: 175).
(2) Skizofreni betyder ”spaltning af sindet”. Betegnelsen rammer
væsentlige sider af symptomatologien, for så vidt som patienterne
ofte frembyder tegn på personlighedsspaltning og på mærkelige
former for splittelse af følelseslivet og tankegangen; de fleste
enkeltfunktioner er intakte, men integrationen svigter. ‘Schizophrenia
means splitting of the mind. The designation hits important aspects
of the symptomatology, as the patients often display signs of splitting
of the personality and of peculiar forms of splitting of the emotional
14 The literal translation of själslivet is ‘the soul life’ cf. German Seelenleben.
Mannsåker: Metaphor and metonymy in the portrayal of schizophrenia
69
life and the reasoning; most of the individual functions are intact, but
the integration fails’ (Smith/Strömgren 1956: 133).
(3) Det som nå er det mest karakteristiske for det schizofrene
tilstandsbillede ved siden av de enkelte grunnforstyrrelser på
tenkings, fölelses og viljeslivets område er den spalting av
personligheten – depersonalisasjonen – som samtidig er til stede og
som foranlediget Bleuler til å betegne lidelsen som schizofreni, hvilket
oversatt betyr spaltet sinn. ‘What is now the most characteristic of the
schizophrenic state15 apart from the individual basic disturbances of
the faculties of thinking, emotion and volition is the splitting of the
personality – the depersonalisation – that is concurrently present and
that caused Bleuler to designate the disorder as schizophrenia, which
translates to split mind’ (Langfeldt 1951: 363-4).
As examples 1–3 show, the stems are used to describe both the diagnosis and
the diagnosed, and the authors do not distance themselves from the metaphoric
expressions by using quotation marks or the like.
There seems to be a shift in the usage of the stem sløv- from the 1900 to the 1950
and 2000 sub corpora. Generally, the stem is used for describing a chronic end
state:
(4) Den sørgelige Udgang af alle ikke helbredede Sindssygdomme, som
ogsaa af mange organiske Hjernelidelser, er Dementsen, Sløvsindet,
Ɔ: Dissociationen, Opløsningen af Personligheden. ‘The sad outcome
of all uncured mental disorders, like that of many organic brain
disorders, is the dementia, the blunt-mind(edness), Ɔ:16 the
dissociation, the dissolvement of the personality’ (Friedenreich
1901: 103).
(5) Drejer det sig om helt sløve, såkaldte ”udbrændte” skizofrene, har
behandlingen ikke store chancer. ‘In cases of completely blunt [sløv-
AGR], so-called “burned out” schizophrenics, the treatment does not
stand much chance’ (Smith/Strömgren 1956: 153).
But in the 1950 and 2000 sub corpora the authors sometimes use the stem for
describing temporary or seeming states, thus signalling a less pessimistic view:
(6) Visse plutselige oppklaringer hos schizofrene pasienter som en
tilsynelatende skulle tro var helt slövet, taler også for at den
schizofrene “demens” iallfall i flere tilfeller er av reversibel natur.
‘Certain sudden clearances in schizophrenic patients who one would
15 The noun tilstandsbilde is a compound of tilstand ‘state’ and bilde ‘image’.
16 Ɔ: = ‘that is’.
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think were completely blunted [sløv-PTCP], also indicate that the
schizophrenic “dementia” at least in several cases is of a reversible
nature’ (Langfeldt 1951: 359).
(7) Man må hele tiden ha for øye at den schizofrene pasients
menneskelige verdighet må respekteres selv om han frembyr aldri så
akutte symptomer, eller skulle synes aldri så sløvet. ‘One must always
keep in mind that the schizophrenic patient’s human dignity must be
respected, regardless of the acuteness of the symptoms he displays, or
how blunted [sløv-PTCP] he seems’ (Malt et al. 2003: 212).
Moreover, three of the six instances of the stem sløv- in the 2000 material are
found in a section explaining the origin of Kraepelin’s dementia praecox
concept, not the current view of the diagnosis. This indicates that the diagnosed
persons are not regarded as genuinely and/or permanently blunted/demented
in the 1950 and 2000 textbooks, as opposed to the 1900 textbooks.
The stem -flat- seems to have replaced avstump- in the 2000 textbooks, -flat- being
more neutral. Avstumpet is defined in a Norwegian dictionary as ‘blunt [sløv],
emotionless’, examples including “avstumpet samvittighet” ‘blunted
consciousness’.17
Several of the instances of the stems split- and spalt- describe the patients’
personality in the 1950 material, in constructions such as “den schizofrene
spaltning av personligheten” ‘the schizophrenic splitting of the personality’
(Langfeldt 1951: 342, 348) or “personlighedsspaltning” ‘personality splitting’
(Smith/Strömgren 1956: 133). In the 2000 material, the stems do not describe the
patients’ personality, but in some instances, the patients’ minds or the patients’
selves: “opsplitning af selvet” ‘splitting up of the self’ (Parnas et al. 2009: 265),
“inre splittring” ‘inner splitting’ (Cullberg 2003: 290).
The perhaps most striking stem is oppløys- (‘dissolv-‘), which is used once in the
1900 material, eight times in the 1950 material and sixteen times in the 2000
material. The stem has quite dramatic connotations, as something that dissolves,
is disintegrated, and often transforms into another form. Often it is the patient
or his personality that is described as “dissolved”, but occasionally it is the
perception, the thinking or the ‘I-boundary’ of the schizophrenic person. Some
17
https://ordbok.uib.no/perl/ordbok.cgi?OPP=avstumpa&ant_bokmaal=5&ant_nyn...
begge=+&ordbok=begge (17.03.2021).
Mannsåker: Metaphor and metonymy in the portrayal of schizophrenia
71
of the instances of the stem in the 2000 material seem to be first-hand accounts
of schizophrenia, expressing subjective symptoms: “følelse af indre
disintegration og opløsning” ‘feeling of inner disintegration and dissolvement’
(Parnas et al. 2009: 264), “oplevelse af kropslig opløsning “ ‘experience of bodily
dissolvement’ (ibid.), “patienten oplever en opløsning af egen person“ ‘the
patient experiences a dissolvement of his own person’ (ibid.: 266), “han føler at
han går i oppløsning eller er i ferd med å spaltes” ‘he [the patient] feels that he
is dissolving or being split’ (Malt et al. 2003: 205), “frykt for mental oppløsning“
‘fear of mental dissolvement’ (ibid.: 224).
So-called self-disturbance is common in schizophrenia (Nelson et al. 2012). The
subjective experience of being an autonomous entity, i.e., an individual (Latin
individuus ‘indivisible’) can be lost. Elyn Saks, a professor in both law and
psychiatry who herself has schizophrenia, writes: “In any case, whatever
schizophrenia is, it’s not ‘split personality’, although the two are often confused
by the public; the schizophrenic mind is not split, but shattered” (2007: 303).
This raises the question of whether the authors’ use of these metaphors is
inspired by the patients’ use of such metaphors or vice versa? Or perhaps there
is a reciprocal influence? The metaphor of dissolvement may possibly be an apt
description of a subjective experience that is common in schizophrenia. It is
nevertheless questionable for a textbook author to use such metaphors without
hedging or signalling.
8.2 What metonymic role(s) do schizophrenia/ schizophrenic play in the
descriptions of the diagnosis and the diagnosed?
In his 1911 monograph on schizophrenia Bleuler implicitly argued that
Schizophrenie is better suited for word formation than Dementia praecox18:
Leider konnten wir uns der unangenehmen Aufgabe nicht entziehen,
einen neuen Namen für die Krankheitsgruppe [Dementia praecox] zu
schmieden. Der bisherige ist zu unhandlich. Man kann damit nur die
Krankheit benennen, nicht aber die Kranken, und man kann kein
Adjektivum bilden, das die der Krankheit zukommenden Eigenschaften
bezeichnen könnte, wenn auch ein verzweifelter Kollege
bereits „präcoxe Symptome” hat drucken lassen. ‘Unfortunately, we
cannot avoid the unpleasant task of coining a new name for the group
18 The Scandinavian term ungdomssløvsinn is equally unfit for word formation.
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of disorders [dementia praecox]. The present one is too cumbersome.
It can only refer to the disorder, not the disordered, and one cannot
from the term derive an adjective in order to designate the
characteristics that accompany the disorder, even if a despaired
colleague already has published „praecox symptoms“ in print’
(1911/2014: 4).
Bleuler stressed the scientific need for a derived adjective in both 1908 and 1911.
And after introducing the noun Schizophrenie on the first page of his 1908 article,
he starts without further notice to use the adjective schizophren a few pages later.
To investigate the usage of Bleuler’s two new terms, I searched for all the
instances of the noun and the derived adjective in his article and in the sub
corpora. In Bleuler’s article the adjective actually outnumbers the noun,
whereas the opposite is the case in the 1950 and 2000 sub corpora. Table 2
displays both the distribution of the noun versus the adjective (in numbers and
per cent) and the frequency relative to the total number of words in the article
and in each of the sub corpora (in per mille).
Bleuler (1908) 1950 sub corpus 2000 sub corpus
N % ‰ N % ‰ N % ‰
Adjective 38 64,4 3,5 263 37,0 6,9 381 37,9 5,2
Noun 21 35,6 1,9 447 63,0 11,8 625 62,1 8,5
In total: 59 100,0 5,3 710 100,0 18,7 1006 100,0 13,7
Table 2: Distribution of the adjective (schizophrenic) versus the noun (schizophrenia)
The adjective is used c. half as often as the noun in the textbooks. It is far more
frequent in the textbook sub corpora than in the article. Both Bleuler’s new noun
and the derived adjective thus seem to be considered useful by the authors.
For further investigation, I did a close reading of the context of each of the
instances of the adjective: 57 in Bleuler’s article, 710 in the 1950 textbooks and
1006 in the 2000 textbooks (cf. Table 2). I found that the adjective serves the
following three functions in the article as well as in the sub corpora:
 Characterising or classifying persons diagnosed with schizophrenia. The
most frequent combination of the adjective + a person-referring noun in
the textbooks is schizophrenic patient(s).
Mannsåker: Metaphor and metonymy in the portrayal of schizophrenia
73
 Referring to someone diagnosed with schizophrenia. In this form of use
the adjective functions as a noun. This is a type of SALIENT ATTRIBUTE FOR
PERSON-metonymy. More precisely it is a DIAGNOSIS FOR DIAGNOSEDmetonymy.
One example from the textbooks is “den familien den
schizofrene er vokset opp i” ‘the family in which the schizophrenic has
grown up’ (Malt et al. 2003: 203). This function is probably what Bleuler
(1911/2014: 4) had in mind when pointing out that “[m]an kann damit
[with Dementia praecox] nur die Krankheit benennen, nicht aber die
Kranken“ ‘with dementia praecox one can only refer to the disorder, not the
disordered’.
 Classifying aspects of schizophrenia in the form of so-called metonymic
compressions. This is a type of metonymy where for example cause–effect
relationships are compressed into an attribute of one of the entities
involved. The most frequent adjective–noun combination of this type in
the textbooks is schizophrenic symptom(s). This is a metonymic
compression because it is the person with schizophrenia who has the
attribute ‘schizophrenic’, not her symptoms. This function is probably
what Bleuler (ibid.) had in mind when speaking about an adjective “das
die der Krankheit zukommenden Eigenschaften bezeichnen könnte” ‘that
can designate the characteristics accompanying the disorder‘. It could
also be said to constitute the opposite of the person-referring function of
the adjective, as compressed constructions enable exclusion of reference
to the person, as in “tidligere histologiske funn i schizofrene hjerner”
‘previous histological [‘pathological’] findings in schizophrenic[-AGR]
brains’ (Langfeldt 1951: 349).
The frequency and distribution of the three functions is presented in Table 3.
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Bleuler (1908) 1950 sub corpus 2000 sub corpus
N % ‰ N % ‰ N % ‰
Characterising persons 1 2,6 0,1 45 17,1 1,2 112 29,4 1,5
Referring to persons 13 34,2 1,2 114 43,3 3,0 142 37,3 1,9
Metonymic
compressions
24 63,2 2,2 104 39,5 2,7 127 33,3 1,7
In total: 38 100,0 3,5 263 100,0 6,9 381 100,0 5,1
Table 3: Distribution of the three functions of the adjective schizophrenic
Although schizophrenic in its basic sense is an adjective referring to a human
attribute, the literal use of the adjective is markedly less frequent than the other
two types. In the article the use of metonymic compressions is more frequent
than the person-referring use, whereas the opposite is true for the sub corpora.
The non-metonymic/literal characterising function is however relatively more
frequent in the 2000 textbooks than in the article and the 1950 textbooks.
8.3 Metonymic and non-metonymic use of the adjective schizophrenic
The literal use of the adjective is by no means uncontroversial. In the 1990s a
linguistic strategy called person first [or people first] language was formulated.
This strategy is practised for example by the UN in their 2006 convention for
people with disabilities (Granello/Gibbs 2016). A central actor in this development
was the American Psychological Association (APA), who in 1992
published a list of linguistic guidelines for what they call “Nonhandicapping
language”19. One of the principles stated in the guidelines is that adjectives
should be replaced with nouns: a schizophrenic person → a person with
schizophrenia; he is schizophrenic → he has schizophrenia. The rationale behind this
principle is that if the condition is mentioned first, the perception of the person
is negatively coloured in advance, and the condition is given too much focus.
19 https://apastyle.apa.org/6th-edition-resources/nonhandicapping-language (12.02.2022).
Revised: https://apastyle.apa.org/style-grammar-guidelines/bias-free-language/dis....
Mannsåker: Metaphor and metonymy in the portrayal of schizophrenia
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Although the idea of person first language has existed for decades, the practise
is far from fully implemented. Granello/Gibbs (2016) found that recommended
and advised-against constructions are used interchangeably in both the media
and in academic literature, even in texts discussing stigma and the negative
consequences of “labels”. As Table 3 shows, the 2000 sub corpus contains a
considerable number of instances of these controversial constructions, albeit
relatively fewer than the 1950 sub corpus.
As mentioned above, person-referring use of the adjective schizophrenic reflects
a DIAGNOSIS FOR DIAGNOSED-metonymy, where a person is referred to by
means of an adjective derived from the name of his psychiatric diagnosis. The
diagnosis functions as what Langacker (1999) calls a reference point to the
diagnosed person. Langacker (1999: 199) sees metonymy as a type of reference
point construction. He mentions the example “The {vasectomy/herniated disk} in
room 304 needs a sleeping pill. [one nurse to another in a hospital]” and comments
that the example
[…] illustrates the skewing of salience relationships that specific
circumstances often induce. In a hospital setting, nurses may well
know virtually nothing about their individual patients except the
nature of their malady or medical procedure; this is what they are
primarily responsible for dealing with. Consequently, when they
have to mention a particular patient (whose name they may not even
recall), the malady or procedure suggests itself as an obvious
reference point (ibid.: 200).
For psychiatrists a person’s psychiatric diagnosis is of course very salient and
important; it is – in Langacker’s words – what they are primarily responsible for
dealing with. But unlike Langacker’s examples of diagnoses, a vasectomy and a
herniated disk, mental disorders are often chronic and very stigmatised.
Psychiatry differs from somatic medicine in important ways. Having a
herniated disk does not cause people to see you differently or fear you, but
being diagnosed as having a mental disorder may have these consequences. As
the psychiatrist Nancy Andreasen writes in the text “What is psychiatry”:
“Because our minds create our humanity and our sense of self, our speciality
cares for illnesses that affect the core of our existence” (Andreasen 1997: 592).
While the various parts of our bodies have clearly defined functions, the mind
has not, and therefore people with severe mental disorders are often regarded
as completely dysfunctional rather than partially dysfunctional (Lauveng 2005;
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Rustand 2007). To perceive the person as equivalent with her illness or
diagnosis seems to be a way of thinking that still exists to some extent in mental
health care, and this way of thinking affects the patients. Person-referring use
of adjectives such as a schizophrenic depicts the person as nothing more than a
wandering diagnosis.
In expressions like a schizophrenic the person and the diagnosis have merged
into a single entity, whereas expressions like a person with schizophrenia contain
separate references to the person and the diagnosis, thus separating the
diagnosis from the person.
It is worth noting that person-referring use of adjectives relating to psychiatric
diagnoses is in fact absent from the 1900 sub corpus, except for one instance of
the manic in Friedenreich (1901/2009). Based on my findings for schizophrenic I
investigated the use of the adjectives hebephrenic, catatonic, paranoid, hysterical
and melancholic in the same way in the three sub corpora. These adjectives occur
relatively often in the textbooks and denote attributes belonging to the domain
of dementia praecox/schizophrenia or a more encompassing domain where
dementia praecox/schizophrenia is an element. None of these adjectives are
used in a person-referring way in the 1900 sub corpus, although they are just as
linguistically suitable for such use as schizophrenic and are indeed used in this
way in the 1950 and 2000 sub corpora. Person-referring use of adjectives
specifically related to a diagnosis seem to have appeared in the textbooks after
the release of Bleuler’s 1908 article, where the person-referring use of
schizophrenic constituted c. 1/3 of the instances of the adjective.
8.4 Metonymic use of the noun schizophrenia
Another difference between Langacker’s (1999: 199) and my examples, is that
vasectomy and disk are nouns, and schizophrenic is an adjective. The noun
schizophrenia is rarely used metonymically to refer to persons in the sub corpora,
and most of the instances of this function are found in the 1950 sub corpus.
While the adjective used as a noun always refers to a person, the noun
schizophrenia primarily refers to the disorder, and it scarcely ever refers to the
person alone. What is more often the case, is that the abstract and uncountable
noun schizophrenia through what Bierwiaczonek (2013: 117–118) calls minor
conversions, i.e., “ordinary conceptual metonymies based on a shift in construal”
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77
(ibid.: 117), has become concrete and countable and seems to refer to both the
disorder and the person.
Three instances of person-referring use are found in Bleuler’s article:
(8) Durch zwei Doktorandinnen […] habe ich die während 8 Jahren im
Burghölzli aufgenommenen 647 Schizophrenien in bezug auf die
Prognose durcharbeiten lassen. ‘With the help of two female Ph.D.
students I have during the last eight years at Burghölzli been able to
work through the 647 admitted schizophrenias regarding the
prognosis‘ (Bleuler 1908: 437).
(9) Wir bekommen nur einen sehr beschränkten Teil aller Schizophrenien
in unseren Anstalten zur Beobachtung […]. ‘We only receive a very
limited portion of all schizophrenias into our institutions for
observation‘ (ibid.: 461).
(10) Dafür werden ganz leichte Schizophrenien durch eine interkurrente
Zornaufwallung, einen Zuchthausknall, eine manische Erregung,
einen Selbstmordversuch, einen pathologischen [sic] Rausch in die
Anstalt gebracht. ‘On the other hand, fairly light schizophrenias are
sent to the institution because of an intercurrent fit of rage, a prison
psychosis, a manic excitement, a suicide attempt, a pathological
intoxication‘ (ibid.).
In the 1950 sub corpus there are four examples:
(11) […] et stort materiale lobotomerte schizofrenier […] ‘a large material
of lobotomized schizophrenias’ (Langfeldt 1951: 395).
(12) […] de tilfeller av “schizofreni” som ble helt restituert etter
operasjonen […] ‘those cases of “schizophrenia” [relative pronoun]20
were fully recovered after the surgery’ (ibid.).
(13) Journaler over schizofrenier. ‘Medical records of schizophrenias’
(Smith/Strömgren 1956: 155).
(14) På grunn av lidelsens kroniske natur og nödvendigheten av
forpleining i anstalt for et flertall av tilfellene, utgjör schizofreniene
overalt et flertall av asylenes klientel. ‘Because of the chronic nature
of the disorder and the necessity of asylum care for a majority of the
cases, the schizophrenias everywhere constitute a majority of the
clientele of the asylums’ (Langfeldt 1951: 345).
20 In Norwegian, the relative pronoun is som both for personal and non-personal antecedents.
It is not possible for me to know for certain if Langfeldt would have used ‘who’ or ‘that’ in
English.
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In 11–14 the noun schizophrenia is clearly referring to persons diagnosed with
schizophrenia because it is persons who are lobotomised, persons who may
recover after surgery, persons who have medical records and persons who are
admitted to and receive care in institutions and constitute a part of their
clientele.
The noun schizophrenia is however mostly used literally in the textbooks, i.e., to
refer to the diagnosis/disorder, cf. the expressions in italic in 15–16:
(15) Skizofrenien er den i social henseende vigtigste sindssygdom.
‘Schizophrenia is the socially most important mental disorder’
(Smith/Strömgren 1956: 133).
(16) Diagnosen skizofreni er en klinisk diagnose, og der findes ingen robuste,
spesifikke (potensielt diagnostiske) biologiske markører for
sygdommen. ‘The diagnosis schizophrenia is a clinical diagnosis, and
there are no robust specific (potentially diagnostic) biological markers
for the disorder’ (Parnas et al. 2009: 247).
But in some instances, it is unclear if the noun primarily refers to the disorder
as an abstract phenomenon or to concrete manifestations of it, or to the person(s)
with schizophrenia. According to Croft (2003) metonymy can often be viewed
as the highlighting of a domain in a domain matrix. Several domains in the
matrix may be highlighted at once by different contextual triggers. He illustrates
this phenomenon by the example “I cut out this article on the environment”,
where the noun article refers to both OBJECT and CONTENT, triggered by cut out
and on the environment respectively. The same seems to be the case for some of
the instances of schizophrenia in both the article and the sub corpora. In 17–18
the noun seems to simultaneously refer to the disorder and a case of the disorder
or the patient (contextual triggers are in italic):
(17) I omkring 10 % av tilfellene av schizofreni har stoffmisbruk gått forut for
sykdommens debut […]. ‘In c. 10 % of the cases of schizophrenia drug
abuse has preceded the onset of the disorder’ (Malt et al. 2003: 203).
(18) Behandlingen af skizofreni er i een henseende en utaknemmelig
opgave, for så vidt som man ikke kan gøre sig håb om fuldstændig at
helbrede disse patienter. ‘The treatment of schizophrenia is in one way a
thankless task, as one cannot hope to fully heal these patients’
(Smith/Strömgren 1956: 150).
It is a one-to-one relation between a case of schizophrenia and the person who
has schizophrenia. Having schizophrenia is not the same as having a cold; one
does not get well from schizophrenia and then later contract a new case of
Mannsåker: Metaphor and metonymy in the portrayal of schizophrenia
79
schizophrenia. And schizophrenia only manifests itself in the form of concrete
cases. A case of schizophrenia is in this respect equivalent to a person with
schizophrenia – on the one hand a manifestation of the disorder, on the other a
unique person with a unique case of the disorder:
(19) Der Begriff “abnormer Charakter” ist aber ein groβer Topf, in dem die
verschiedensten Abweichungen vom Normalen Platz haben – namentlich
auch latente, chronisch verlaufende Schizophrenien, welch letztere
natürlich die Gesamtprognose beeinflussen können. ’The concept of
“abnormal character“ is very heterogenous, containing all sorts of
deviations from the normal – even latent, chronic courses of
schizophrenias, the last of which may influence the overall prognosis‘
(Bleuler 1908: 439).
(20) […] ebenso wirkt der Alkohol nur indirekt deletär, indem er auch
leichte Schizophrenien auf seine verschiedenen Weisen in der
Gesellschaft unmöglich macht ‘likewise, alcohol only has an indirect
harmful effect, in that it in its various ways renders even light
schizophrenias impossible in society‘ (ibid.: 452).
(21) I over halvparten av tilfellene av schizofreni vil vi finne at pasientene
som barn har vært innadvendte, ofte oppfattet som nervøse eller
følsomme. ‘In more than half of the cases of schizophrenia we will find
that the patients as children have been introverted, often perceived as
nervous or sensitive’ (Malt et al. 2003: 204).
Sometimes the context clearly highlights one of the aspects:
(22) […] at de tilfeller av schizofreni som reagerte gunstig på lobektomiene,
for det meste var pasienter hos hvem det kunne påvises affektive
tilblandinger og exogen genese ‘that those cases of schizophrenia
[relative pronoun] reacted favourably on the lobectomies were mostly
patients where affective elements and exogenous genesis could be
found’ (Langfeldt 1951: 395).
(23) […] i tilfeller av schizofreni som har vart i årevis […] ‘in cases of
schizophrenia [relative pronoun] has lasted for years and years’
(Langfeldt 1951: 395).
The noun schizophrenia can thus have ambiguous or double reference. This kind
of vagueness, where more than one interpretation is possible, is not unusual in
cases of metonymic meaning extensions based on conceptual contiguity
according to Halverson (2012). The contiguity relations between the person and
the disorder are strong, and therefore the boundary between them can easily
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disappear, cognitively as well as linguistically. The same is true for expressions
referring to treatment – you can (linguistically) treat the patient or the disorder:
(24) behandling av schizofreni ‘treatment of schizophrenia’ (Malt et al.
2003: 212);
(25) behandling av pasienten ‘treatment of the patient’ (ibid.: 214).
And you can (linguistically) diagnose the patient or the disorder:
(26) Visse selvmutilerende patienter lider af anhedoni og dårlig
impulskontrol og diagnostiseres fejlagtig som borderline. ’Certain selfmutilating
patients suffer from anhedonia and lack of impulse control
and are diagnosed as borderline’ (Parnas et al. 2009: 300).
(27) En psykose kan saktens være diagnostisert som en reaktiv psykose
innledningsvis, og ende opp som en schizofren lidelse, uten at man
kan si at den opprinnelige diagnosen var feil. ‘A psychosis may well
be diagnosed as a reactive psychosis initially and end up as a
schizophrenic disorder, one can however not claim that the initial
diagnosis was wrong’ (ibid.: 212).
Metonymic person-referring use of schizophrenia is marginal in the textbooks
compared to metonymic person-referring use of schizophrenic, perhaps because
the former is ambiguous in terms of reference, while the latter is not. It could
also be the case that person-referring use of the noun is perceived as (even) more
problematic than person-referring use of the adjective, as the latter construction
is easy to ameliorate by inserting a person-referring noun such as ‘patient’ or
‘person’ or the like after the adjective. The adjective denotes an attribute of the
person, whereas the noun denotes an entity other than the person. To refer to
the person by means of the actual name of the disorder is more marked than
referring to the person by means of the name of a salient attribute.
8.5 The adjective schizophrenic in metonymic compressions
Metonymic compressions involving the adjective schizophrenic are widespread
in both Bleuler’s article and the sub corpora. The adjective is used attributively
to modify a wide range of nouns that have the following in common: a) they do
not refer to persons with schizophrenia and b) they can be said to refer to
elements or sub elements in a domain of schizophrenia that includes both
aspects of the disorder and aspects of the person suffering from the disorder.
Bleuler (1908) uses the adjective attributively in 25 of 26 instances, and only one
of the 25 instances participates in a construction referring to a person, namely
Mannsåker: Metaphor and metonymy in the portrayal of schizophrenia
81
“die latent schizophrene, aber bis dahin ganz arbeitsfähige Witwe” ‘the latent
schizophrenic, but until then quite employable widow’ (Bleuler 1908: 455). The
other 24 instances are used in metonymic compressions, as listed in Table 4.
Noun N Element
Symptom ‘symptom’ 8 Symptom
Assoziationsstörung ‘disturbance of
associations’
2 Symptom
Zeichen ‘sign’ 1 Symptom
Blödsinn ‘imbecility’ 2 State
Demenz ‘dementia’ 1 State
Anfall ‘fit’ 1 Course
Prozeß ‘process’ 3 Course
Krankheitsprozeß ‘disease process’ 2 Course
Hirnprozeß ‘brain process’ 1 Course
Psyche ‘psyche’ 2 Psyche
Gedankengang ‘way of thinking’ 1 Mental functions
Table 4: Frequency of nouns denoting elements in the domain of schizophrenia and participating
in metonymic compressions with the adjective schizophren in Bleuler’s 1908 article
Table 5 displays the frequency and distribution of all the instances of the nouns
that are used in metonymic compressions in the 1950 and 2000 sub corpora. The
noun types are sorted in categories based on which schizophrenia-related
element or aspect they refer to. The categories 1a-c consist of aspects of the
disorder and 2a-c consist of aspects of the person.
metaphorik.de 32/2022
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1950 2000
N % N %
1a. Disorder 19 18,3 32 25,2
1b. Symptom 27 26,0 46 36,2
1bi. Attributes of symptom or state related
to schizophrenia
2 1,9 2 1,6
1bii. The products of the schizophrenic
person21
5 4,8 0 0
1c. Course 19 18,3 22 17,3
2a. Family 2 1,9 2 1,6
2b. State 8 7,7 17 13,4
2c. Psyche/Body 16 15,4 2 1,6
2ci. Mental functions 6 5,8 4 3,1
In total: 104 100,0 127 100,0
Table 5: Frequency and distribution of nouns denoting elements in the domain of
schizophrenia and participating in metonymic compressions with the adjective schizophrenic
in the 1950 and 2000 sub corpora
In 28–36 I provide each of the categories in Table 5 with an example from the
textbooks, translated into English by me. I have formulated a tentative
paraphrase after each example.
(28) Disorder: ‘schizophrenic borderline conditions’, i.e., ‘conditions that
resembles schizophrenia but do not meet all the criteria for
schizophrenia’
(29) Symptom: ‘schizophrenic symptom’, i.e., ‘symptom associated with
and considered to be caused by schizophrenia’
21 Different forms of observable behaviour may be considered symptoms of the disorder. I have
therefore chosen to place the ’products’ of the person under SYMPTOM, as for example letters, drawings
and paintings may be affected by the disorder and/or be interpreted as signs of one of the symptoms
of the disorder, namely delusions and disorganisation in the form of thought. These ‘products’ are
mentioned in psychiatric textbooks by virtue of being regarded as tangible indications of the mental
state of the ‘producer(s)’.
Mannsåker: Metaphor and metonymy in the portrayal of schizophrenia
83
(30) Attributes of symptom or state: ‘language and thought disturbances
of schizophrenic nature’, i.e., ‘language and thought disturbances
associated with and considered to be caused by schizophrenia’
(31) Products: ‘schizophrenic letters’, i.e., ’letters that in form and content
reflect or indicate a type of thought disturbances associated with and
considered to be caused by schizophrenia’
(32) Course: ‘the schizophrenic process’, i.e., ‘the gradual change
(deterioration) of mental state and level of functioning associated with
and considered to be caused by schizophrenia’
(33) Family: ‘the schizophrenic family’, i.e., ‘a family where one member
has schizophrenia’
(34) State: ‘a schizophrenic state’, i.e., ‘a state associated with and
considered to be caused by schizophrenia’
(35) Psyche/Body: ‘schizophrenic inheritance’, i.e., ‘inherited genetic
disposition for schizophrenia’
(36) Mental functions: ‘schizophrenic world’, i.e., ‘the world view of a
person who apparently has lost contact with reality, presumedly
because of schizophrenia’
To put my findings in Table 4 in perspective, I investigated the adjectives
psychotic, hebephrenic, catatonic, paranoid in the same way. Since these adjectives
are older than schizophrenic, I have included the 1900 sub corpus as well as the
1950 and 2000 sub corpora in the investigation, thus making it possible to see if
metonymic compressions were used in the textbooks before Bleuler introduced
the adjective schizophrenic in 1908. The distribution of metonymic attributive use
(compressions) versus non-metonymic attributive use (characterising/
classifying persons) in the entire corpus is 180:23 for psychotic, 53:7 for
hebephrenic, 153:13 for catatonic and 154:9 for paranoid. The construction is widespread
in all three sub corpora and its function is to classify various phenomena:
Som bestanddele af de typiske sygdomstilfælde indgaar: 1. Det
hebefrene sløvsind. 2. Den katatone villiesforstyrrelse. 3. De
paranoide vrangtanker og 4. Neurastheniforme, resp. 5.
Melankoliforme initialstadier. ‘Components of the typical cases of the
disorder are: 1. The hebephrenic dementia. 2. The catatonic
disturbance of volition. 3. The paranoid delusions and 4. neurastheniform,
resp. 5. melancholiform initial stages (Vogt 1905: 119).
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The use of schizophrenic thus fits into a pattern in psychiatric textbooks where
attributively used adjectives related to states and diagnoses are mainly used in
metonymic compressions.
Specific language communities or genres often develop their own sets of
metaphors and metonymies. According to Littlemore et al. (2010) metonymy
makes communication more effective by functioning as short cuts within the
discourse community, while at the same time posing problems for outsiders.
Littlemore et al. discuss the example “loose nappy”, an idiosyncratic metonymic
compression used in a day nursery. The expression does not refer to a loosefitting
nappy, it describes the state of the bowels of the baby whose nappy needs
changing. In the same way as schizophrenic symptoms are not ‘schizophrenic’, the
adjective loose does not refer to a property of the nappy. It takes sufficient inside
knowledge to know what these expressions mean.
Could metonymic compressions like schizophrenic symptoms in addition to
functioning as short cuts also function as resorts when one tries to conceptualise
and describe complex and enigmatic phenomena such as schizophrenia? By
using the adjective schizophrenic in compressions, the addresser leaves the
responsibility of identifying the relation between the adjective and the noun to
the addressee. The metonymic compressions in the textbook corpora are not
surrounded by any explanatory paraphrases or elaborations. Bleuler himself
frequently uses schizophren in metonymic compressions (cf. Table 3), and he
does not attempt to paraphrase, explain, or clarify these expressions.
Paraphrasing the compressions entails trying to formulate the relation between
the adjective and the noun. But this is still just an oversimplification of complex
connections and causal mechanisms. The explanatory value of the paraphrase
is not materially different from that of the compression, since the terms
schizophrenic and schizophrenia both refer to complex phenomena that are not yet
sufficiently known or understood. Metonymic compressions consisting of the
adjective schizophrenic + a noun that is related to the domain of schizophrenia
have existed for as long as the terms schizophrenic and schizophrenia have existed,
and the construction seems to be very productive. Moreover, this construction
is not unique for the adjective schizophrenia in the textbooks. Metonymic
compressions are probably widespread in all forms of scientific language. They
are economic and, more importantly, they enable exclusion of reference to
Mannsåker: Metaphor and metonymy in the portrayal of schizophrenia
85
agents and causal relations, entities that are often unknown or difficult to
describe precisely.
9. Conclusion
Metaphor and metonymy play several roles in the naming and description of
the disorder and the disordered. Both dementia praecox (‘prematurely out of
one’s mind’), ungdomssløvsinn (‘youth-blunt-mind(edness)’) and schizophrenia
(‘split mind’) are metaphors, but they are also metonymies, as one (assumed)
aspect of the disorder is used to name the whole disorder: outcome for dementia
praecox and ungdomssløvsinn and cardinal symptom for schizophrenia.
The terms dementia praecox, ungdomssløvsinn and schizophrenia are all based on
metaphors where the mind is conceptualised as a physical object with physical
properties: lack of co-localisation in the case of dementia, lack of desired sharpness
in the case of sløvsinn and lack of unity in the case of schizophrenia. These
metaphors are all implicit negative assessments: co-location, sharpness and unity
have positive connotations and their opposites thus have negative connotations.
The change of name from dementia praecox/ungdomssløvsinn to schizophrenia
seems to have caused a change in the metaphor use in the textbook corpus –
before the introduction of the term schizophrenia, none of the textbooks describe
the disorder or the patients with the word ‘split’ or synonymous expressions,
but after the name change such descriptions are being used. This indicates that
it was not just the name of the disorder that changed, but also the scientific
conceptualisation of the disorder. Bleuler’s metaphoric term has also impacted
laypeople’s conceptualisation of the disorder, as well their lexicon: A common
misconception of schizophrenia is that it is equivalent to ‘split personality’, and
schizophrenia and schizophrenic are now established as colloquial metaphors for
inconsistency and contradiction in many languages.
The adjective schizophrenic is used metonymically far more often than it is used
literally, and there are two types of metonymical use. The first type is nounal
use of the adjective to refer to the diagnosed person, as in ‘schizophrenics’ or
‘a/the schizophrenic’. This is a SALIENT ATTRIBUTE FOR PERSON-metonymy, or,
more precisely, a DIAGNOSIS FOR DIAGNOSED-metonymy, where the person and
the diagnosis linguistically (and perhaps also conceptually) have merged into a
single entity and the person is depicted as a wandering diagnosis. The second
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type of metonymic use of the adjective is metonymic compressions such as
‘schizophrenic symptoms’ (i.e., symptoms associated with and considered to be
caused by schizophrenia). This kind of construction enables the exclusion of
reference to the person suffering from (the symptoms of) schizophrenia. It may
also serve as a convenient resort for conceptualising and describing complex
and enigmatic phenomena such as schizophrenia because it also enables the
exclusion of reference to agents and causal relations.
The noun schizophrenia is hardly ever used metonymically to refer solely to
persons, but occasionally it seems to refer both to the person and the disorder.
This is not surprising, as the contiguity relations between the disorder on the
one hand and a case of the disorder and a person with the disorder on the other
hand are strong, and the boundary between them can thus easily disappear,
cognitively as well as linguistically.
Both the ‘split personality’-connotations of the metaphoric term schizophrenia
and the DIAGNOSIS FOR DIAGNOSED-metonymy are likely to contribute to the
stigmatisation and self-stigmatisation associated with the disorder and the
persons suffering from it. On the other hand, excessive use of metonymic
compressions without reference to the person(s) with schizophrenia may lead
to a reductionist and technical depiction that underplay the fact that
schizophrenia is a disorder that causes considerable and often incapacitating
symptoms for the persons afflicted with it.
There is an ongoing discussion in psychiatry as to whether to replace
schizophrenia with a new name. Lasalvia et al. (2015) list the names proposed in
the literature, and the suggestions are either eponyms: Kraepelin-Bleuler Disease
and Bleuler’s disease or multiword expressions: Neuro-Emotional Integration
Disorder (NEID), Salience Dysregulation Syndrome, Youth onset CONative,
COgnitive and Reality Distortion syndrome (CONCORD), Dysfunctional Perception
Syndrome (DPS), Psychosis Susceptibility Syndrome (PSS). Lasalvia et al. (ibid.)
recommend choosing an eponym, because it is neutral as far as connotations are
concerned, thus preventing misinterpretations and misconceptions. The same
argument, one should remember, was in fact made by Kraepelin in 1909: “[…]
a name that as far as possible said nothing would be preferable […]”
(Kraepelin/Barclay 1909/1911: 4).
According to Noll (2011) the attraction of Bleuler’s schizophrenia (which in
many ways is an antithesis of “a name that as far as possible say nothing”) was
Mannsåker: Metaphor and metonymy in the portrayal of schizophrenia
87
that of therapeutic hope: “psychological processes that were split could,
theoretically, be reunited” (ibid.: 239), whereas Kraepelin’s dementia praecox
offered no therapeutic hope. The hope Noll refers to, resides in the metaphoric
entailments of schizophrenia, but the term also has more sinister connotations,
and it is the latter that seem to dominate society’s conception of the disorder
and the persons suffering from it. Moreover, to literally name a mental disorder
characterized by delusions, hallucinations, and disturbances in self-experience
‘split mind’ hardly seems therapeutic or reassuring. As Lauveng (2005: 138)
puts it: “[…] diagnoser innebærer kategorisering av mennesker, og det vil alltid
være annerledes enn å kategorisere ting som mynter eller frimerker. Mennesker
vet hva som skjer, og de blir påvirket av det, på godt og vondt.“ ‘[…] diagnoses
entail categorisation of human beings, and this will always be different to
categorising things like coins or stamps. Human beings know what is
happening, and they are affected by it, for better or worse.’
The names currently proposed as replacements for schizophrenia have one thing
in common: It is not possible to derive an adjective from any of them. Several
studies have found that in colloquial use the adjective schizophrenic is far more
frequently used metaphorically than the noun schizophrenia (Chopra/Doody
2007; Magliano et al. 2011; Joseph et al. 2015; Mannsåker 2020), cf. Sontag (1979),
who claims that when an illness becomes a metaphor, it becomes adjectival.
Based on my examination of the usage of schizophrenic and semantically related
adjectives in the textbooks, I am tempted to claim that when a psychiatric
disorder or state becomes adjectival, it becomes a metonymy in scientific
language (and possibly a metaphor in colloquial language). If schizophrenia
should be replaced with one of the proposed terms, it will be interesting to see
how one manages without an accompanying adjective, and, furthermore, to see
what metaphoric expressions the new name is accompanied by.
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