Introduction

“Dangerous” and “unpredictable”! In efforts to counteract this toxic stereotype of the “schizophrenic”, some destigmatization programs have tried to persuade the public to adopt the biological/medical paradigm that currently dominates the mental health field with slogans such as “mental illness is an illness like any other”. Others have pointed out, however, the growing body of literature demonstrating that adoption of an illness model increases, rather than decreases stereotyping, prejudice and fear [1]. All, on both sides of this debate, however, agree that the media often fuels the stereotypes and fear.

Since the late 1950s, studies have pointed out that media portrayal of the mentally ill is largely based on the stereotypes [2–13]. On US TV, one in four mentally ill characters kill someone, and half are portrayed as assaulting others, with an offence rate tenfold that of other television characters [14, 15]. In 1991, Shain and Phillips [16] reported that up to 75% of newspaper articles on mental illness were focused on aggressive behaviors. Although this percentage was found to be lower in more recent surveys, it is still around 30% [17, 18]. In addition, articles about recovery are virtually absent in print media [19, 20], and those which do focus on treatments present psychotropic drugs as substances leading to dependence, or psychosocial interventions which do not distinguish between evidence-based therapies and less tried and tested methods [6, 15].

In a UK study, three-fourth of mental health service users affirmed that media portrayal of mental illness was inaccurate and impartial, and one-third stated that it negatively influenced the attitudes of their relatives and friends toward them, as well as the individuals’ opportunities to find a job [21]. Furthermore, health professionals pointed out that media images of mental illness rendered communicating psychiatric diagnoses, such as schizophrenia, to patients and their relatives more difficult [22–25].

Media images of mental illnesses may interfere with users’ access to mental health services and adherence to treatments, and it may increase family burden and stigma [22, 26–32]. Evidence suggests that newspaper reporting may also influence mental health policy in unbalanced ways, and constitute an obstacle for the implementation of community-oriented mental health care [10, 18, 33–36].

In some circumstances, however, the media has been a powerful resource to increase social acceptance of mentally ill [37]. For example, in Italy, the promulgation of 1978 psychiatric reform law (“Law 180”) was supported by the media which raised lay people’s awareness of the conditions of inmates in asylums and those subjected to early attempts at community care [38].

In 1978, Sontag [39] observed that illnesses whose etiologies are considered mysterious are more likely to be used metaphorically as a reflection of stigmatizing beliefs. Among mental illnesses, schizophrenia is probably the most incomprehensible and certainly involves one of the highest levels of stigma [11]. As pointed out by Choopra and Doody [40], schizophrenia may represent the illness as a metaphor of the twenty first century, a role that cancer played in the mid to late twentieth century and tuberculosis in the nineteenth century.

While numerous studies have been carried out on media and mental illness, relatively few have specifically focused on media portrayal of schizophrenia. Research on how schizophrenia is reported in newspapers found that in 11–58% of cases this term is used as a metaphor for unpredictability or ambiguity, mainly in politics and cultural/arts articles [19, 20, 40–43]. In two studies, more negative connotations were found when the term is used as an adjective rather than a noun [40, 43]. In addition, violent crimes relating to persons with this diagnosis are frequently in the media limelight, reinforcing the belief that schizophrenia is closely associated with dangerousness [19, 20, 40–43]. In an Italian study of secondary school students [44], 76% stated that their knowledge of mental illness came only from mass media: 19% were firmly convinced that persons with schizophrenia were more aggressive than the general population and 44% that they were unpredictable.

This study examined how the term schizophrenia is used in Italian print newspapers.

In particular, the following hypotheses were tested:

  1. (a)

    that the term schizophrenia, when used as a metaphor mainly portrays incoherence/contradiction/split;

  2. (b)

    that the term schizophrenia, when used non-metaphorically, mainly refers to aggressive acts by persons diagnosed with mental illness.

Methods

The survey was carried out on the 22 Italian newspapers which allow word scanning on their online website. Of these 22 newspapers, 4 (18%) were broadsheets with national circulation, and 9 (41%) were broadsheets with regional or local circulation, respectively. In each newspaper, the terms “schizophrenia” (singular and plural form) and “schizophrenic” (singular and plural, and masculine and feminine) were scanned in all articles, from January 1, 2008 to December 31, 2008.

Each article containing schizophrenia/schizophrenic was evaluated in terms of: its use (metaphoric vs. non-metaphoric), the section (politics, news, economy/finance, science/health, and culture/entertainment/sport), the reference (to a person, to the illness, to a group/abstract concept), and the grammar form (noun vs. adjective). Metaphoric use was classified as follows: incoherence/contradiction/split, dangerousness/aggressiveness, and eccentricity/oddness.

The classification of metaphoric use of the term “schizophrenia” was developed by the authors on the basis of previous literature on this topic and a preliminary content analysis of Italian newspapers’ articles. Inter-rater reliability in the use of the metaphor classification was formally tested on 50 randomly selected articles. These were independently rated by two authors (L.M. and R.M.) in relation to use of the term, the reference, and the type of metaphor (Cohen’s kappa coefficient: 1.0, 0.89, and 1.0, respectively).

Statistical analysis

Differences in the use of the term schizophrenia (metaphoric vs. non-metaphoric) in relation to grammar form, reference, and section were explored by means of χ2. Variables found to be significantly associated with the term schizophrenia in univariate analysis were included in a logistic regression analysis to explore their simultaneous effect on the probability of metaphoric versus non-metaphoric use of the term (dependent variable). Statistical significance level was set at p < 0.05. Statistical analyses were performed by SPSS version 15.0.

Results

Metaphoric use of the term schizophrenia

As a metaphor, schizophrenia was used in 801 articles out of 1,087 (73.7%), mainly in reference to a group/abstract entity (745, 93.0%) (Table 1). Its meaning was incoherence/contradiction/split in 682 cases (85%), eccentricity/oddness in 84 cases (10.5%), and dangerousness/aggressiveness in 35 (4.4%). Examples are reported in Table 2.

Table 1 Metaphoric and non-metaphoric use of the term “schizophrenia”: differences in relation to grammar form, reference, and newspaper section (N = 1,087)
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Table 2 Examples of metaphoric use of the term schizophrenia
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“Schizophrenia” was used metaphorically more in politics (398, 49.7%) and culture/entertainment/sport articles (281, 35.1%) than in economics/finances (87, 10.9%), news (29, 3.6%), and science/health (6, 0.7%). Of the 281 culture/entertainment/sport articles containing “schizophrenia”, 87 (30.9%) were society, 78 (27.7%) on TV programmes, movies, or dramas, 36 (12.8%) on music, 33 (11.7%) on literature, 32 (11.4%) on sport, and 15 (0.5%) on other topics.

Non-metaphoric use of the terms schizophrenia

The term was used non-metaphorically in 286 (26.3%) articles, of which 209 (73.1%) referred to individuals actually given the diagnosis, and 117 (40.9%) were news (Table 1). Of these 117, “schizophrenia” was mentioned 57 times (48.7%) in articles on homicides or suicide-homicide, 17 (14.6%) in articles on physical assaults or verbal aggression by persons with this disorder, 33 (28.2%) in articles on assaults directed at the person, and 3 (2.6%) in articles on suicides. Examples are reported in Table 3.

Table 3 Examples of non-metaphoric use of “schizophrenia”
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In the 92 articles (44%) of articles in which “schizophrenia” was used non-metaphorically in reference to individuals given the diagnosis, 74 (80.4%) were in culture/entertainment/sport sections. 41 of these 74 (58.1%) were on movies/TV programmes or dramas, 11 (14.9%) on literature topics, 8 on music (10.8%), 2 (2.7%) on society, 2 (2.7%) on figurative arts, 2 (2.7%) on philosophy, and 6 on other topics (8.2%).

Furthermore, 77 articles (26.9%) mentioned the term schizophrenia in reference to the disorder itself: 64 (83.1%) were in science/health sections, 9 (11.7%) in culture sections, and 4 (5.2%) in news sections. As regards science/health section, 20 (31.3%) articles containing “schizophrenia/schizophrenic” were on mental health care and law, 18 (28.1%) on risk factors, 7 (10.9%) on symptoms and course, 6 (9.4%) on genetics, 5 (7.8%) on psychotropic drugs, 3 (4.7%) on neuroscience, 2 (3.1%) on non-pharmacological treatments, 2 (3.1%) on etiology, and 1 (1.5%) on recovery.

Differences in the use of the term schizophrenia (metaphoric vs. non-metaphoric) in relation to grammar form, reference, and section

Schizophrenia was more frequently used as metaphor in its adjective form, in reference to group/entity, in economy/finance articles, in politics articles, and in culture/entertainment/sport articles (Table 1). No statically significant difference was found in the metaphoric versus non-metaphoric usage of “schizophrenia” among newspapers at national (71%), regional (74%), or local circulation (78%, χ2 = 4.8, df = 2, p < 0.09).

Logistic regression revealed that the probability of a metaphoric versus non-metaphoric use of schizophrenia was significantly higher when the term was reported in political articles (B = 2.4, df = 1, p < 0.002), and it was lower in news articles (B = −4.0 df = 1, p < 0.0001; χ2  of the model = 1,078, df = 7, p < 0.0001).

Discussion

This is the first study carried out in Italy to examine the use of the term schizophrenia in print newspapers.

One of the limits of this study is that only newspapers with free online index have been included (33.6% of Italian newspapers), and the results may not be generalizable to all news media.

In 73.7% of articles, the term schizophrenia is used as a metaphor. This percentage is significantly higher than that reported in previous literature, which ranged between 11 and 58% [19, 20, 40–43]. A possible explanation of such an unexpectedly high level of inappropriate use is that Italian language uses a lot of metaphors generally. On the other hand, this finding suggests that Italian journalists are not aware of the effects that the metaphoric use of psychiatric terms may have on stigma associated with these diagnoses [45], and they poorly informed on the characteristics of mental disorders such as schizophrenia [18]. This is probably due to the fact that the level of scientific journalism is generally low [27] because of the literary rather than scientific background to this profession.

In 85% of metaphoric cases, schizophrenia is used to mean incoherence/contradiction/split. This may perpetuate the stereotype of the dangerous, good versus evil “split personality” as portrayed in many films since “Jekyll and Hyde”, increasing social distance toward persons with this disorder [30, 46]. This usage may also contribute to the misconception that schizophrenia is primarily a condition involving unpredictability among mental health service users and the general population. Among persons with mental disorders, negative media images may be perceived as greatly distressing, and may increase self-stigma [9, 47]. This, in its turn, may interfere with users’ social participation and the recovery process. In general population, unpredictability was found to be associated with low level of acknowledgement of civil and affective rights of persons with this mental disorder [48]. Unfortunately, the cross-sectional design of this study does not allow us to test whether this perception has been strengthened over the years in media language as it has in general population studies [49]. This aspect will be specifically addressed in future papers.

The term “schizophrenia” was used as metaphor more often in political articles and in culture/entertainment/sport sections, a finding in line with the results of previous studies [19, 20, 40]. However, the metaphoric meaning of the term varies according to the section. While 388 of 682 (56.9%) of the articles reporting “schizophrenia/schizophrenic” as metaphor of unpredictability are in politics versus 182 (26.7%) in culture/entertainment/sport sections, 6 out 84 (7.1%) of those using the term as eccentricity/oddness were in politics versus 74 (88.1%) in culture/entertainment/sport sections (χ2 = 167.5, df = 8, p < 0.0001). It is likely that the high metaphoric usage as unpredictability in politics is mainly related to the journalists’ desire to reinforce their critical opinions about an issue, while its usage as eccentricity mainly refers to “indulgent” stereotype about creativity and madness.

Concerning the high probability of metaphoric use when the term is used in its adjective form, it is worthwhile to report the Sontag [39] description of leprosy as metaphor, as also cited by Chopra and Doody [40]: “First the subjects of deepest dread (corruption, decay, pollution, anomie, weakness) are identified with the disease. The disease itself becomes a metaphor. Then in the name of the disease the horror is imposed on other things. The disease becomes adjectival. Something is said to be disease-like, meaning that it is disgusting or ugly. In French, a mouldering stone façade is still lepreuse”. It is likely that this process has also occurred in schizophrenia.

The high metaphoric use of the term schizophrenia should be also considered in relation to the large use of the term madness in mass communication [13]. In Italy, a recent ministry campaign on violence said: “violence on women is madness” [50]. The campaign, broadcast and reported on newspapers and leaflets, aimed to sensitize general population on gender violence by using the association madness–social dangerousness.

Although literature data show that persons with schizophrenia are more frequently victims than perpetrators of violence [51–54], 35 articles used the term schizophrenia metaphorically to mean dangerousness. A further 74 articles reported crimes carried out by persons with this disorder, while only 33 described news where these persons were victims of violence. These data confirm previous studies showing that the media disproportionately report negative stories about people diagnosed with “schizophrenia”, and in particular, equate the diagnosis with violence.

The emphasis given to crime news involving persons diagnosed with schizophrenia should be also interpreted in light of the increased perception of social dangerousness in Italy and of need to control deviant behaviors. These perceptions are probably one of the motivations behind the submission to Parliament of several proposals to modify current Italian psychiatric law, which is currently more balanced and humanitarian than in many other countries where “mental patients” have fewer human rights. These proposals give high relevance to coercive psychiatric treatments, in some cases with the declared aim of controlling “dangerous behaviors” of persons with mental illnesses [55].

The results of this study indicate a need for intervention in relation to Italian journalists to address this situation. In particular, the following strategies should be considered: (a) to increase the collaboration between mental health and media professionals; journalists should be properly informed about mental illness and sensitized to the effects that metaphoric use of psychiatric terms, such as schizophrenia, may have on stigma and on users’ experience of stigma; (b) to promote the organization of groups of users, relatives, journalists, and mental health professionals to monitor the use of psychiatric terms in media [56]; (c) to prompt Italian media associations to develop deontological protocols on reporting news about mental illness as already adopted for news about other groups who are discriminated against [57]; such initiatives are ongoing in other countries in order to promote responsible journalism principles in reporting on mental health issues [58–61]; and (d) to institute a national prize for journalists reporting mental health-related topics appropriately as recently launched by the European Commission [62]. This year, the first and the third prize were won by articles on schizophrenia. As reported in the Public Health Portal of the European Union, these articles won because they “…deal with issues that matter to the individual and to society. They address topics which are associated with fear and/or stigma…(they) tackle the subject in a very original and personal way with positive messages of living and coping with the disease”.

From a research point of view, further studies in this area are needed. These studies should specifically address the following topics: (a) journalists’ conceptions of causes and psychosocial consequences of schizophrenia; (b) the impact of media use of the term schizophrenia on the stigma perceived by users with this mental disorder and their relatives; (c) the media use of other psychiatric terms, such as depression and panic; and (d) the metaphoric usage of psychiatric terms on television, mainly in politics talk-shows and entertainment programmes.