Documente Academic
Documente Profesional
Documente Cultură
So Paulo
2010
ii
So Paulo
2010
iii
Autorizo a reproduo e divulgao total ou parcial deste trabalho, por qualquer meio
convencional ou eletrnico, para fins de estudo e pesquisa, dede que citada a fonte.
FICHA CATALOGRFICA
Estudo transversal de dois anos das informaes sobre a esquizofrenia divulgadas no maior
jornal dirio Brasileiro/ Maria Thereza Bonilha Dubugras; Orientador: Jair de Jesus Mari
So Paulo, 2010. 147 p.
BANCA EXAMINADORA:
DEDICATRIA
dos artistas.
vii
AGRADECIMENTOS
Em especial, ao Prof. Dr. Jair de Jesus Mari, pela preciosa orientao durante todo o
curso de doutorado e a realizao da pesquisa, por sua dedicao, incentivo, confiana
e por seus ensinamentos, desde o meu mestrado, sobre o que fazer cincia.
Dra. Denise Razzouk, presente desde a elaborao do projeto de pesquisa, por suas
valiosas sugestes para a redao dos artigos, por seu apoio incondicional e amizade.
Dra. Cleide Aschenbrenner Consales, por suas sugestes para a pesquisa, apoio e
amizade.
Neiva Regina de Souza por suas valiosas sugestes para a formatao final do
trabalho e pela reviso do texto em lngua portuguesa.
Dra. Maria do Carmo Custdio de Souza Lara, amiga sempre presente, pronta
para apoiar e sugerir os melhores caminhos.
Aos meus amigos Dr. Alexandre Loureno e Profa. Dra. Lilian Gregory, fontes de
idias sobre como divulgar a cincia.
A minhas irms, Beatriz, Ceclia e Elisa e a toda a minha famlia pelo apoio e torcida
a cada novo projeto.
RESUMO
Dubugras MTB. Estudo transversal de dois anos das informaes sobre a esquizofrenia
divulgadas no maior jornal dirio Brasileiro [tese]. So Paulo: Universidade Federal de
So Paulo, 2010. 147p.
Objetivos: Descrever e analisar as informaes sobre a esquizofrenia presentes em textos com
temtica relacionada sade e em textos sobre outros temas, publicados no jornal Folha de
So Paulo (FSP), entre 1/1/2007 e 31/12/2008. Metodologia: Foi realizada uma busca
eletrnica dos textos, utilizando-se os seguintes termos: esquizofrenia, esquizofrnico(a)(s),
surto, psicose, psictico(a)(s). Foi realizada a anlise de contedo. As informaes sobre a
esquizofrenia presentes em textos relacionadas rea da sade foram sintetizadas e
comparadas com o conhecimento disseminado em revistas cientficas. Foi determinado o uso
popular dos termos em textos no relacionados rea da sade. Adicionalmente, os textos
foram avaliados em relao aos atributos de uma comunicao em sade efetiva, examinou-se
a presena de indicadores de uma cobertura jornalstica inadequada e de mitos populares sobre
a doena mental. Resultados: Foram identificados 687 textos, 219 deles preencheram os
critrios de incluso e excluso: 75 textos relacionados rea da sade e 144 em que os
termos eram usados fora do contexto mdico. As categorias temticas com maior nmero de
textos entre aqueles da rea da sade foram a distrbio e violncia e o tratamento. Entre os
textos no relacionados sade, os termos foram identificados em resenhas de filmes
cinematogrficos, descries populares do distrbio (incluindo caractersticas que no
corresponde definio mdica), expresses pejorativas, expresses humorsticas. O uso
metafrico dos termos associou ao distrbio as caractersticas de contradio,
diviso/multiplicidade, falta de sentido e conflito, entre outras; 80% das metforas tinham
uma conotao negativa. Concluso: A FSP divulgou informaes sobre os fatores genticos
da esquizofrenia e sobre os benefcios da medicao psicotrpica o que pode contribuir para
uma percepo mais favorvel das intervenes psiquitricas. Adicionalmente, descreveu
histrias sobre portadores com vidas produtivas e inseridos na comunidade, entretanto, os
relatos de crimes cometidos por supostos portadores superaram em nmero e em destaque os
exemplos positivos, o que pode anular qualquer outra mensagem que poderia contribuir para o
combate do estigma da esquizofrenia. Os resultados sugerem que a complexidade do
distrbio, os diversos fatores etiolgicos, as diferenas individuais e as alternativas
teraputicas, no foram abordados. Os textos com uso popular dos termos associou a
esquizofrenia violncia ou criatividade, bem como divulgaram mitos e imagens
estigmatizantes. O dilogo entre profissionais de comunicao, da sade e associaes de
familiares e portadores pode melhor a qualidade da cobertura da imprensa sobre a doena
mental.
Palavras-chave:
Psiquiatria. Esquizofrenia. Comunicao em Sade. Jornalismo em sade. Estigma.
x
ABSTRACT
SUMRIO
1. INTRODUO ..................................................................................................... 12
1.7. Justificativa.............................................................................................................. 59
3. MTODO ............................................................................................................... 69
1.INTRODUO
Einstein
13
Plato (427-348 a.C.) distinguiu as doenas do corpo e da alma. Concebeu a alma (Psych)
constituda por trs partes - a racional (Logistikon), responsvel pelo conhecimento abstrato; a
apetitiva (Epithymoeides), ligada s necessidades corporais mais elementares e
sobrevivncia; e a afetivo-espiritual (Thymoeides), elo funcional entre a parte racional e a
parte instintiva. O distrbio mental, chamado por ele de demncia ou desrazo, era uma das
doenas da alma, sendo resultado da desarmonia entre as trs partes da Psych. A desrazo
(Anoia) poderia ser de duas espcies: a loucura (Mania) e a ignorncia (Amathia). Na obra
Fedro, Plato descreve a desrazo de origem divina (a loucura visionria ou proftica,
influncia de Apolo; a loucura potica, inspirada pelas musas; o delrio exttico causado por
Dionsio e o delrio ertico, atribudo a Eros) e a desrazo causada por alteraes humorais
(Melancholiks). Dessa forma, concordava com a medicina hipocrtica, entretanto, acreditava
tambm na interferncia divina na vida dos seres humanos (Pessotti, 1994).
Para Aristteles (384-322 a.C.), a medicina deveria ser um sistema filosfico racional para
constituir um conhecimento. Em seu tratado De Anima, definiu a alma como sendo
constituda por uma parte racional e outra irracional, localizadas no corao e dependentes do
calor vital, as alteraes bruscas de temperatura causariam a loucura, o excesso de calor
produziria a excitao e o frio excessivo, as depresses (Pessotti, 1994).
15
Reginald Scot1 (1584, apud Porter, 2002) questionou a existncia da possesso demonaca,
defendeu que as bruxas deviam ser tratadas e no temidas e punidas, pois sofriam de uma
perturbao da imaginao. Nessa poca, os anglicanos igualmente questionaram a existncia
da bruxaria e a necessidade do exorcismo e do adorcismo. Sobretudo a partir de 1650, as
elites educadas excluram o diabo das explicaes da loucura. Os mdicos substituram
progressivamente os padres no cuidado com os doentes. Apesar disso, Porter (2002) assinala
a persistncia da crena na bruxaria e na possesso na a populao e mesmo em parte da elite,
incluindo alguns mdicos.
Entre os sculos XIV e XVII, a lepra, antigo flagelo, praticamente desapareceu da sociedade
ocidental. Nessa poca, os incurveis, pessoas com doenas venreas e os insanos, foram
levados para os antigos leprosrios. A imagem popular sobre os leprosos e os insanos era
contraditria. Por um lado, eram considerados como portadores do mal (a doena e o mau
1
Scot R. The Discovery of Witchcraft (1584). Brinsley Nicholson (Totowa, NJ, 1973).
16
O termo psicose foi grafado pelo mdico alemo Feuchtersleben (1806-1849) em 1845, a
partir da palavra Psych [alma] acrescida do sufixo osis [doena] para nomear a insanidade
em geral, incluindo as categorias tradicionais de melancolia, mania, demncia e idiotia, como
subcategorias das neuroses definidas por Cullen (Beer, 1996). Com o termo, Feuchtersleben
pretendia indicar que os distrbios mentais no seriam exclusivamente doenas do corpo ou
da mente, e sim doenas da personalidade. Em 1846, o termo foi utilizado no peridico
Zeitschrifte fur Psychiatrie und Gerichtliche Medizin, entretanto s foi usado na Frana em
1869. O primeiro trabalho que utilizou o termo com destaque foi de Mbius, em 1892, que
dividiu os distrbios mentais em psicoses exgenas e endgenas. Quando Kraepelin fez a sua
primeira sistemtica, no utilizou o termo, porm, o incluiu nos tratados seguintes (Lopes,
2001).
desconexas, um tipo de existncia automtica" (Pinel2, 1803 apud Jablensky, 1986). Outra
descrio da poca que pode se referir a quadros de esquizofrenia foi feita por Haslam em
1809.
Bndict Augustin Morel (1809-1873) empregou pela primeira vez a expresso Dmence
Prcoce (demncia precoce) ao relatar um caso de desorganizao do pensamento em um
menino de 14 anos casos de idade. Descreveu um quadro de decadncia cerebral da segunda
dcada, desde o acesso agudo, sobrevindo com aparente benignidade, at a fase final de
dissoluo psquica, passando por uma etapa intermediria de torpor e agitao, considerou
que se tratava de uma afeco de natureza constitucional, incluindo-a no grupo das loucuras
hereditrias de existncia intelectual limitada, com transio irremedivel idiotia
(Shirakawa, 2009).
Em 1871, Hecker descreveu a hebefrenia, uma sndrome que acomete jovens, com acessos
sucessivos, enfraquecimento mental rpido, transtornos da linguagem e da escrita e
maneirismos (Shirakawa, 2009).
O psiquiatra alemo mil Kraepelin (1856-1926) props a definio das patologias mentais
de acordo com curso e o desfecho, ao invs do conjunto de sintomas. Inaugurou o mtodo
clnico na psiquiatria, descartando a abordagem baseada em especulaes morais (Elkis,
2000). Em 1896, Kraepelin reuniu os quadros descritos por Morel, Hecker e Kahlbaum em
2
Pinel P. Nosographie philosophique ou la mthode d'analyse applique la mdecine. Paris,
Marandon; 1803.
18
uma entidade nica, includa na 4a edio de seu tratado, Lehbuch der Psychiatrie. Para
nome-la, utilizou a forma latina do termo criado por Morel Dementia Praecox:
Em 1908, Paul Eugen Bleuler (1857-1939) props modificaes nos conceitos da demncia
precoce, em sua monografia Demncia Precoce ou o Grupo das Esquizofrenias (Dementia
praecox oder die gruppe der schizophrenien), publicada em 1911. Sugeriu a reunio das
diferentes formas do transtorno no Grupo das Esquizofrenias, bem como que deveria ser
considerado que o transtorno poderia ter um incio mais tardio e a possibilidade da
deteriorao progressiva no ser uma regra (nem sempre demncia, nem sempre precoce).
Bleuler criou o termo esquizofrenia, atravs da unio das palavras gregas skhizein (:
ciso) e phrn, (: mente), para representar a caracterstica do grupo de transtornos de
diviso de diferentes funes psquicas, uma forma especfica de alterao do pensamento,
dos sentimentos e da relao com o mundo externo (Bleuler, 1911). Ao contrrio de
Kraepelin, Bleuler privilegiou os sintomas e no o curso e o desfecho do distrbio para sua
descrio, propondo a subdiviso da sintomatologia em sintomas fundamentais e acessrios
(Elkis, 2000; Razzouk e Shirakawa, 2001).
19
O PSE foi usado no exame de pacientes de nove pases, no Estudo Piloto Internacional da
Esquizofrenia (International Pilot Study of Schizophrenia, IPSS), pesquisa patrocinada pela
Organizao Mundial da Sade, cujo objetivo era verificar invariantes da esquizofrenia. O
IPSS concluiu que a esquizofrenia era um transtorno psiquitrico universal, com alguns
sintomas comuns, independente da cultura local: a falta de insight, alucinaes auditivas e
verbais, sonorizao do pensamento, embotamento afetivo, ideias e delrios de referncia
(Elkis, 2000). Durante o IPSS, alguns pesquisadores observaram que os SPO tinham grande
20
Nas dcadas de 1960 e 1970, foram realizados estudos clnicos e epidemiolgicos com o
desenvolvimento e validao de escalas de diagnstico para a comparao de sistemas de
diagnstico. Comparando a prevalncia de diagnsticos dos Estados Unidos com a da
Inglaterra, Cooper et al. (1987) demonstraram que a prevalncia da esquizofrenia varia de
acordo com o critrio de diagnstico adotado.
Em 1972, Feighner et cols. da Escola de St. Louis elaboram o primeiro critrio diagnstico
operacional, tendo sido baseado nos sintomas de Schneider (delrios e alucinaes), Bleuler
(falta de organizao lgica) e em Langfeld (ajustamento pr-mrbido pobre, histria familiar
de esquizofrenia, incio da doena antes dos 40 anos, sem alcoolismo ou toxicomania at um
ano antes do incio da psicose e ser solteiro). Esse sistema a base para o Research
Diagnostic Criteria (RDC), desenvolvido por Spitzer et al. (1978). O RDC inclui critrios
para a excluso de doenas afetivas e o perodo mnimo de duas semanas de sintomas
estabelece uma classificao para o curso e subdivide a esquizofrenia nas formas paranoide,
desorganizada, catatnica, indiferenciada e residual (Razzouk e Shirakawa, 2001).
Utilizando a anlise fatorial, Liddle (1987) definiu trs dimenses principais da esquizofrenia:
forma positiva, negativa e desorganizada. Na forma positiva ocorre a distoro da realidade
(alucinaes e delrios), a forma negativa est relacionada pobreza psicomotora
(empobrecimento do discurso; embotamento afetivo; diminuio espontnea dos
movimentos; diminuio da mmica facial) e a desorganizada inclui o distrbio formal do
pensamento; inadequao afetiva e empobrecimento do discurso (Razzouk e Shirakawa,
2001).
A Classificao Internacional das Doenas (CID) foi criada em 1893, como Classificao de
Bertillon ou Lista Internacional de Causas de Morte. Na atualidade, utilizam-se os critrios
22
O termo estigma surgiu na Grcia Antiga: stizein (estigma) era um sinal colocado no corpo
dos escravos, criminosos e dos traidores para evidenciar o status moral inferior de quem os
apresentava. Poderiam ser cortes ou marcas feitas a fogo sinalizando um ser ritualmente
poludo, a ser evitado, especialmente em lugares pblicos (Goffman, 1975).
No Gnesis, aps assassinar seu irmo, Caim condenado por Deus a ser peregrino e errante
sobre a terra, nada do que plantasse renderia frutos. O Criador faz nele um sinal para
24
identific-lo como um assassino, entretanto, essa marca tambm o protege: aquele que matar
Caim ser punido sete vezes (Gnesis, 4:10-15).
O Senhor disse-lhe: Que fizeste! Eis que a voz do sangue do teu irmo
clama por mim desde a terra. De ora em diante, sers maldito e expulso da
terra, que abriu sua boca para beber de tua mo o sangue do teu irmo.
O Senhor ps em Caim um sinal, para que, se algum o encontrasse, no o
matasse (Gnesis, 4:10-15).
A partir do sculo XIII, surge na tradio crist o dogma dos estigmas, ferimentos que
apareciam em pessoas de muita f, durante estados de xtase religioso, representando as cinco
chagas de Jesus crucificado (Simpson, 1984). Os estigmatizados eram privilegiados que
conseguiam uma verdadeira identificao com o sofrimento fsico e moral de Cristo no
momento da paixo. Os estigmas tidos como verdadeiros pela Igreja eram considerados
milagres e alguns estigmatizados foram depois canonizados, como So Francisco de Assis
(1182-1226), o primeiro a ter esses sinais. O carter positivo do estigma de proteo ou de
sinal de santidade, existente na histria de Caim e no martrio dos santos - se perdeu no
mundo moderno. Na modernidade, o termo usado de maneira semelhante ao sentido literal
original, uma sinalizao sobre quem possui atributos indesejveis e deve ser rejeitado pelo
grupo (Goffman, 1975).
Jones et al. (1984), utilizam o termo marca, consideram que o processo de estigmatizao
iniciado quando condies consideradas desviantes, caractersticas indesejveis aos olhos da
sociedade so atribudas ao indivduo. Em seu modelo de estigma, os autores propuseram seis
variveis que determinam a estigmatizao: a capacidade de ocultao (o quanto a
caracterstica percebida por outros, dependendo da natureza da condio e da capacidade do
indivduo de escond-la), o curso (se a condio reversvel ou no, quando irreversvel,
causa mais atitudes negativas da sociedade), a capacidade de ruptura (o quanto interfere nas
25
relaes interpessoais), a esttica (a extenso em que a condio causa uma reao instintiva
ou afetiva de averso), a origem (como a condio se instalou, quando percebida como
causada pelo prprio indivduo, gerando atitudes negativas e ideias de punio), e o quanto
pode representar um perigo, como a ameaa fsica, ou causar sentimentos desagradveis,
como culpa ou desconforto.
Goffman (1975) define trs tipos de estigmas: as abominaes do corpo (as deformidades
fsicas), as culpas de carter individual (incluindo os distrbios mentais e os comportamentos
desviantes) e os estigmas tribais (motivados pela raa, nacionalidade e religio). Por no
considerar algum com um estigma como totalmente humano, a sociedade exerce vrias
discriminaes, utiliza termos especficos para nomear o indivduo e supe existirem outras
imperfeies como tambm atributos, igualmente fora da normalidade, como por exemplo,
poderes sobrenaturais, o que pode explicar a contradio existente na imaginao popular
sobre a loucura em certos momentos vista como sinal de talento artstico, em outros como
um sinal de agressividade.
Os familiares dos portadores de distrbios mentais (stman e Kjellin, 2002; Leff e Warner,
2006) e os profissionais de sade mental (Leff e Warner, 2006) podem igualmente ser
estigmatizados e serem estigmatizadores. Goffman (1975) chama o preconceito e a
discriminao a que os familiares esto sujeitos de estigma de cortesia: quando as pessoas
prximas so obrigadas a compartilhar o descrdito associado ao indivduo estigmatizado.
O estigma pode ser o principal obstculo para a reintegrao social dos portadores de
esquizofrenia, pode provocar a diminuio da autoestima e o retraimento social do indivduo
afetado (Thornicroft, 2006; Leff e Warner, 2006), pode causar problemas financeiros,
marginalizao social, e discriminao no sistema judicial (Sosowsky, 1980; Thornicroft,
2006). Evidncias sugerem que um fator importante para recadas e re-hospitalizaes
(Penn et al., 2000), bem para o risco de suicdio (Eagles et al., 2003). O estigma direcionado
aos transtornos mentais e ao tratamento psiquitrico pode levar a uma menor destinao de
verbas para a rea da sade mental (Corrigan e Watson, 2003; Matschinger e Angermeyer,
2004). Estudos realizados em diferentes pases revelaram que a esquizofrenia um dos
transtornos mais estigmatizados pela populao (Crisp et al. 2000; Angermeyer, Matschinger,
2003; Griffiths et al., 2006).
Atravs de da pesquisa realizada por Wahl (1999), portadores de distrbios mentais relataram
que as fontes de estigma so de diversas naturezas, incluindo a comunidade, a igreja, colegas
de trabalho e cuidadores. A maioria dos respondentes afirmou esconder ser portador de
distrbio mental, entretanto, o segredo no alivia o problema, pois temem que os outros
descubram sua condio. Os portadores relataram terem diversos sentimentos diante do
estigma desnimo, dor, raiva, o resultado final a baixa auto-estima. Destacam que
necessrio educar a populao sobre a realidade dos distrbios, pois acreditam que assim ser
possvel eliminar o preconceito e a discriminao com que eles tm que conviver diariamente.
Alguns dos respondentes declararam que estar envolvidos em aes de advocacia os ajudava
a lidar com a dor resultante do estigma.
27
Sontag (1989) destacou que a reduo do estigma pode ser obtida atravs da divulgao de
informaes, para a populao, sobre a etiologia e o tratamento da doena estigmatizada. A
imprensa pode colaborar para o esclarecimento da populao sobre a esquizofrenia. Qual
seria a abordagem mais adequada, quais informaes devem ser divulgadas?
Read et al. (2006; 2007) sugeriram que a promoo junto ao pblico do modelo biomdico,
com a nfase nos fatores etiolgicos genticos da esquizofrenia, atravs da mensagem de ser
uma doena como outra qualquer, pode aumentar a percepo de periculosidade dos
portadores e o estigma. Dessa forma, sugerem que sejam destacados os fatores psicolgicos
para a etiologia do distrbio. Jorm e Griffiths (2008) no confirmaram essa hiptese em um
estudo na Austrlia.
Ao testar a hiptese de Read et al. (2006; 2007), Jorm e Griffiths (2008) no identificaram
que o entendimento da esquizofrenia a partir do modelo biomdico fosse o fator mais
importantes para o estigma, e sim a associao da esquizofrenia com uma fraqueza de
carter e o comportamento dos portadores, associado s incapacidades geradas pelo
distrbio. Desta forma, os autores destacam que para a reduo do estigma necessrio o
aprimoramento das intervenes para a reduo das incapacidades geradas pelo distrbio,
bem como o esclarecimento da populao sobre os fatores etiolgicos, para contrapor a
percepo popular de que um resultado de uma fraqueza de carter.
Star3 (1955 apud Peluso, 2004) e Cumming, e Cumming4 (1957 apud Peluso, 2004)
contriburam para as pesquisas sobre conhecimentos e atitudes em relao aos transtornos
mentais com inovaes metodolgicas. Star (1955) desenvolveu vinhetas para apresentar, em
linguagem coloquial, descries comportamentais de indivduos portadores de esquizofrenia
simples e paranoide, alcoolismo, neurose de ansiedade, transtorno de carter juvenil e fobia
compulsiva, utilizando-as em um estudo sobre a percepo de 3.500 indivduos norte-
americanos sobre os transtornos. Apenas uma pequena parte dos entrevistados identificou as
condies como distrbios mentais, sendo que considerava os transtornos ameaadores e por
isso no desejava ter contato com portadores.
3
Star S. The Public's ideas about mental illness. Paper presented at the annual meeting of the National
Association for Mental Health, Indianapolis, Ind. 1955.
4
Cumming E, Cumming J. Closed ranks. An experiment in mental health education. Cambridge:
Harvard University Press, 1957.
31
Link et al. (1999) aplicaram questionrio com vinhetas representando indivduos com
esquizofrenia, depresso maior, dependncia alcolica, dependncia de cocana e a descrio
de uma pessoa com problemas que no caracterizavam transtorno mental, utilizando uma
amostra representativa de 1.444 indivduos. Foram avaliados os seguintes aspectos: a
identificao do transtorno, suas causas, a periculosidade dos indivduos portadores desses
transtornos e a distncia social desejada desses indivduos. Os resultados indicaram que a
maior parte da amostra identificou esquizofrenia e, em menor grau, depresso maior como
distrbios mentais. Por outro lado, menores parcelas do pblico associaram o abuso de lcool
e drogas s doenas mentais. Foram relatadas causas de natureza diversa, combinando
circunstncias estressoras com fatores biolgicos e genticos. Os sintomas dos distrbios
mentais permaneceram fortemente associados violncia em potencial e h desejo de
interao social limitada.
Lauber et al. (2001) questionaram qual seria o tratamento mais adequado para a depresso e a
esquizofrenia para uma amostra representativa da populao sua (n = 1.737), por meio de
entrevistas por telefone. Para os respondentes, os tratamentos mais adequados so o
atendimento com psiclogos, clnicos gerais, tomar ar puro e a assistncia psiquitrica.
Dentre os tratamentos psiquitricos, o mais valorizado foi a psicoterapia, enquanto o uso de
medicao ou eletroconvulsoterapia (ECT) foi considerado pouco til. O tratamento
psiquitrico foi considerado mais til para a esquizofrenia do que para a depresso.
32
Como o Canad foi o pas escolhido para o projeto piloto na Campanha Global de Combate
ao Estigma e Discriminao Devidos Esquizofrenia da Associao Mundial de Psiquiatria
(WPA), foram realizados diversos estudos sobre atitude e conhecimento da populao sobre o
transtorno, para auxiliar o planejamento de aes e se conhecer a situao inicial do
problema, visando avaliar seus resultados. Stuart e Arboleda-Flrez (2001) avaliaram a
atitude da populao de duas regies adjacentes (rural e urbana) da provncia de Alberta, os
resultados indicaram que metade da amostra conhecia algum que foi tratado por ser portador
da esquizofrenia ou de outro distrbio mental. Os fatores etiolgicos mais identificados foram
os fatores biolgicos, o transtorno foi descrito com maior frequncia como uma doena do
crebro. O desejo por uma distncia social dos portadores aumentou de acordo com o nvel
de envolvimento necessrio. Pessoas com mais de 60 anos tinham menor conhecimento e
maior distanciamento social. Indivduos com maior conhecimento da esquizofrenia
apresentaram menor desejo de distanciamento. Entretanto, quando se controlaram outros
fatores, no foi identificada correlao entre a disposio ao contato com os portadores e o
conhecimento.
Alem et al. (1999) realizaram estudo em uma cidade da Etipia, utilizando o mtodo
desenvolvido pela OMS, para a identificao de atitudes e prticas em relao a diversos
transtornos mentais (retardo mental, epilepsia, psicose aguda, mania, depresso maior,
esquizofrenia crnica e neurose). A esquizofrenia foi considerada o transtorno mais grave,
seguido pelo retardo mental. Falar demais, agresso e comportamento estranho foram
considerados prottipo dos sintomas de doena mental. Os tratamentos tradicionais foram
preferidos para tratar os transtornos mentais e a medicina moderna para os sintomas e
doenas fsicas.
34
Para avaliar a internalizao do modelo organicista do distrbio mental, Tsu e Tofolo (1990)
entrevistaram 60 mulheres que se encontravam internadas em um hospital da cidade de So
Paulo, sendo que quase a totalidade delas apresentava sintomas considerados psicticos. Os
resultados foram coincidentes com os relatados por Jones et al. (1963) e Weinstein e Brill
(1971), as pacientes preferiram considerar uma linha de explicao de cunho psicognico para
o distrbio mental. Os autores sugerem que as explicaes de tipo psicossocial sejam comuns
entre portadores por tornarem o problema mais suportvel, ao possibilitar o entendimento de
que a condio resultado de algo que simplesmente "aconteceu", existindo a esperana da
recuperao e a percepo de outras pessoas em situaes semelhantes tambm esto sujeitas
ao distrbio, enquanto que as concepes organicistas esto normalmente associadas s
ideias de hereditariedade e defeito.
35
Como a esquizofrenia com frequncia incapacitante, cabe aos familiares cuidar e apoiar o
portador, buscar os servios de sade, lidar com as situaes de crise e de no adeso ao
tratamento (Vilares et al., 1999). A sobrecarga familiar (family burden) o impacto causado
no meio familiar pela convivncia com o portador de um distrbio mental (Miles, 1982). Com
o processo de desinstitucionalizao psiquitrica, a nfase nos servios comunitrios de sade
mental e perodos mais curtos de hospitalizao, as famlias dos portadores tm participado
cada vez mais dos cuidados dos portadores (Bandeira & Barroso, 2005), as pesquisas tm
identificado um alto nvel de sobrecarga (Saunders, 2003).
Segundo Tessler e Gamache (2000), a famlia dos portadores de distrbios mentais graves
passa por fases distintas ao longo do tempo. Inicialmente, predominam as reaes de
insegurana, de negao e a expectativa de que profissionais de sade resolvam o problema.
Com a conscientizao do carter crnico da doena, os familiares passam a sentir
desesperana e a buscar mais em seus prprios recursos uma maneira de lidar com a situao.
A postura diante da doena das famlias latinas a de resignao e esperana, enquanto que
na cultura anglo-saxnica predominam atitudes de recriminao e crticas (Sheper-Hughes,
1987).
Para identificar os fatores que influenciam a demora pela procura por um tratamento
adequado, aps o primeiro episdio psictico no Brasil, Monteiro et al. (2006) entrevistaram
15 familiares de portadores que demoraram mais de seis meses para buscar o tratamento
psiquitrico, identificando percepes equivocadas e estereotipadas da doena mental
(inicialmente no achavam que o parente tinha um distrbio mental, pois seu comportamento
no se parecia com o dos lunticos que viam nas ruas ou dos loucos mostrados em
programas de televiso ou jornais, pessoas agressivas e ameaadoras, totalmente fora de
controle), modelos construdos para entender o problema (caracterizado principalmente pela
negao da doena, que seria um problema passageiro de estresse, possesso demonaca ou
influncia de espritos, crise da adolescncia ou parte da personalidade do indivduo), medo
dos tratamentos psiquitricos (considerados agressivos, autoritrios e capazes de prejudicar os
portadores) e experincias anteriores ruins com servios de sade mental. Os autores
destacam que em todos os nveis do processo de elaborao da experincia existem
influncias da cultura, desta forma, os profissionais da sade devem avaliar os significados
elaborados por portadores e familiares para o planejamento de intervenes que mobilizem a
busca pelo tratamento apropriado.
explicitamente como uma doena mental e sim como um um problema com o manejo dos
sentimentos numa estrutura conjunta de corpo e mente frgeis. Essa concepo foi observada
tambm no estudo de Jenkins (1988), com famlias de americanos de origem mexicana nos
Estados Unidos da Amrica, ela possibilita expectativas de recuperao e de cura (Villares et
al., 1999).
No Brasil, Avanci et al. (2002) identificaram que alunos iniciantes do Curso de Graduao
em Enfermagem e Obstetrcia da Escola de Enfermagem de Ribeiro Preto, da Universidade
de So Paulo (EERP-USP), do ano de 1998, mostraram-se autoritrios diante de portadores
de distrbios mentais, com tendncia a um protecionismo bondoso. Pedro et al. (2003)
avaliaram que formandos do mesmo curso eram menos autoritrios, menos benevolentes, e
menos discriminadores com portadores de distrbios mentais em comparao aos
ingressantes, concluindo que a instruo acadmica influenciou favoravelmente a mudana da
percepo dos alunos.
DAmorim (1981) estudou a percepo pblica sobre o distrbio mental, em uma amostra
estratificada de 682 indivduos da comunidade e de 35 profissionais de sade mental em Joo
Pessoa (PB), utilizando cinco vinhetas construdas por Star (alcoolismo, esquizofrenia,
depresso, debilidade mental e distrbios comportamentais). Os resultados evidenciaram que
a esquizofrenia foi o quadro mais reconhecido na comunidade como distrbio mental. A
populao recomendou, principalmente, a procura de ajuda de um psiquiatra e a terapia
psicolgica. A populao identificou, menos frequentemente, o alcoolismo e os distrbios
comportamentais como distrbios mentais do que os profissionais de sade mental.
Coelho e Almeida Filho (2005) avaliaram as concepes sobre doena e sade mental de
moradores de uma rea do litoral norte da Bahia, com indivduos do centro e da margem da
sociedade, constatando mltiplos pontos de vista sobre a normalidade mental, incluindo
posies extremas e opostas (neste mundo, no existe ningum normal, porque todo mundo
desorientado, todo mundo normal, todo mundo tem a cabea boa), a possibilidade da
coexistncia da doena e da sade, ideias de graus de normalidade (existe o normal e o
totalmente normal) e prottipos de pessoa normal, quase-normal e falso-normal, de acordo
com princpios normativos. Segundo os autores, a normalidade total era percebida mais como
um ideal do que uma realidade vivenciada. Como outros estudos conduzidos na regio, os
resultados sugeriram que os indivduos considerados normais eram aqueles que possuam
caractersticas socialmente desejadas (por exemplo, possuir trabalho e uma famlia), como
definiu Goffman (1975). As prticas de normalizao adotadas abrangiam aes de preveno
e promoo da sade mental, associando assistncia mdica, cuidados caseiros e religiosos.
Atravs de um inqurito domiciliar com 500 moradores da cidade de So Paulo, Peluso et al.
(2008) pesquisaram as concepes sobre a etiologia da esquizofrenia e a capacidade de
identificar sintomas da doena. Os fatores mencionados pela populao como mais provveis
de causar a esquizofrenia foram o uso de substncias e fatores socioambientais (problemas na
infncia, problemas familiares, falta de f em Deus e isolamento). Os casos de
esquizofrenia apresentados em vinhetas foram identificados como doena mental por 58,8%
dos indivduos, mas 23,4% afirmaram se tratar de casos de depresso, apenas 2,2% dos
sujeitos os associaram esquizofrenia.
Peluso e Blay (2009) desenvolveram outro inqurito domiciliar, com 1.000 habitantes da
cidade de So Paulo, para examinar as preferncias em relao ao tratamento da esquizofrenia
e da depresso. Os resultados foram semelhantes para os dois distrbios: foram considerados
mais teis os tratamentos no mdicos (ajuda de amigos, reunies em igrejas, exerccios
fsicos) e a psicoterapia. Os indivduos relataram considerar que os tratamentos mdicos,
incluindo a hospitalizao e o ECT, provocam mais danos do que benefcios. O prognstico
dos dois transtornos foi percebido como favorvel. Os autores destacaram a necessidade da
divulgao de mais informaes sobre as alternativas teraputicas, especialmente a respeito
dos tratamentos mdicos.
41
A expresso promoo da sade foi utilizada pela primeira vez em 1923 pelo mdico C. E.
A. Winslow ao definir a sade pblica como a cincia a arte de evitar doenas, prolongar a
vida e promover a sade fsica e mental", no artigo The Evolution of Public Health and its
Objectives, (Winslow, 1923 apud Committee for the Study of the Future of Public Health,
1984).
Em 1946, o mdico canadense Henry E. Sigerist definiu, na publicao em The Place of the
Phisician in Modern Society, quatro reas em que a medicina deveria atuar: promoo da
sade, preveno da doena, recuperao dos enfermos e reabilitao. Segundo Sigerist,
promover a sade proporcionar condies de vida decentes, boas condies de trabalho,
educao, cultura fsica e formas de lazer e descanso, sendo o resultado do trabalho
coordenado de polticos, setores sindicais e empresariais, educadores e mdicos (Terris,
1992).
Em 1974, com o objetivo de reduzir os riscos sade fsica e mental, aumentar o acesso da
populao assistncia e otimizar recursos, o Ministro da Sade e Bem-estar do Canad,
Marc Lalonde, publicou o documento Nova Perspectiva sobre a Sade dos Canadenses,
definindo quatro grupos na determinao do processo sade-doena: biologia humana
(gentica e funo humana); ambiente (natural e social), estilo de vida (comportamento
individual) e a organizao dos servios de sade. A proposta era baseada no pressuposto de
que so as decises individuais, hbitos e comportamentos que determinam os efeitos nocivos
e as doenas, assim, a melhoria da qualidade e o aumento dos anos de vida dependiam da
melhoria de meio ambiente, da moderao de comportamentos de riscos, como o uso de
tabaco e lcool, e da ampliao do conhecimento sobre a biologia humana, atravs das
pesquisas cientficas sobre as enfermidades (Lalonde, 1974; Carvalho, 2004). Conhecido
como Informe Lalonde, o documento recebeu crticas por seu foco na ao individual,
perspectiva comportamental e preventivista (Robertson, 1998; Heidmann et al., 2006), como
tambm pela "culpabilizao das vtimas", a responsabilizao de grupos populacionais por
42
problemas de sade causados por fatores que podem estar fora de seu controle (Crawford,
1977; Labonte, 1993). Entretanto, o documento estimulou as discusses sobre o processo
sade-doena, influenciou as polticas de sade de outros pases e estabeleceu as bases para a
Conferncia Internacional de Cuidados Primrios de Sade de Alma Ata, antiga URSS,
organizada pela OMS e a UNICEF, em 1978.
Em 1984, a OMS discutiu a promoo da sade sob essa perspectiva, divulgando as ideias no
relatrio do encontro promovido pela WHO Regional Office for Europe, propondo que um
dos papis da promoo da sade seria colaborar para a transformao das condies de vida
dos desfavorecidos.
Colmbia (1992), em Jacarta, Indonsia (1997) e na Cidade do Mxico, Mxico (2000), com
a produo de documentos em que os pases, inclusive o Brasil, assumiam o compromisso de
adotar as recomendaes.
A Carta de Ottawa (1986) identificou trs estratgias bsicas para a promoo da sade: a
capacitao (enabling) dos indivduos e das comunidades, a mediao (mediating) entre as
pessoas e o meio ambiente e a advocacia em sade (advocacy), aes para se obter o
compromisso e suporte poltico, bem como a aceitao social para os objetivos de um
programa (Carta de Ottawa, 1986).
Segundo a concepo holstica, a promoo da sade deve obter a sade fsica, mental e
social (WHO, 1998), estando assim baseada na compreenso ampliada de sade adotada pela
OMS (1984) que considera, alm dos fatores biolgicos, a determinao social, econmica e
ambiental da sade.
A promoo da sade mental inclui aes que visam maximizar a sade mental e o bem-estar
da populao (Commonwealth Department of Health and Aged Care, 2000). Os objetivos da
promoo da sade mental devem incluir tambm o combate ao estigma em relao aos
distrbios, pacientes e ao tratamento psiquitrico (Scheffer, 2003).
Pasquali (1978) definiu o termo difuso como o envio de mensagens elaboradas em cdigos
ou linguagens universalmente compreensveis para a totalidade das pessoas; disseminao
cientfica como o envio de informaes cientficas, elaboradas em linguagem tcnica, para
profissionais da rea e pesquisadores intrapares (especialistas da mesma rea) ou extrapares
(especialistas de reas diferentes), e divulgao cientfica, o envio de informaes cientficas
para a totalidade do universo receptor, a sociedade, existindo a transcodificao da linguagem
cientfica para uma linguagem acessvel aos pblicos leigos.
Baseado em Pasquali (1978), Bueno (1984) define dois conceitos: (1) disseminao
cientfica: a difuso de informaes cientficas entre especialistas da mesma rea de pesquisa
ou de reas diferentes; (2) divulgao cientfica: a difuso de informaes cientficas para o
grande pblico em geral, aps a recodificao, isto , a transposio de uma linguagem
48
Epstein (1998) define que a comunidade cientfica "se relaciona consigo mesma, em cada
segmento especializado, e com o resto da sociedade atravs de dois processos
comunicacionais distintos, nomeados por ele como primrio e secundrio, o pesquisador
sugere que a comunicao direcionada para a populao deve utilizar determinadas funes
da linguagem e recursos de retrica para superar a especificidade das linguagens e conceitos
especializados.
Vogt (2006) sugere a utilizao da expresso cultura cientfica, para designar o fenmeno da
divulgao cientfica e a insero no cotidiano da sociedade os temas da cincia e da
tecnologia, por considerar que engloba os conceitos sugeridos pelos outros termos utilizados
e, adicionalmente, expressa o carter cultural da produo e da circulao de informaes
cientficas e os objetivos pelos quais a sociedade deve buscar esse conhecimento:
50
Jos Reis (1964), mdico e um dos pioneiros da moderna divulgao cientfica no Brasil,
igualmente identificava o potencial educativo da divulgao cientfica que pode suprir ou
ampliar a educao escolar. A atividade, segundo ele, deve tambm estimular o interesse,
gerando o desejo da busca permanente pelo conhecimento, despertar o interesse pelos
processos cientficos e no pelos fatos isolados e seus personagens, e discutir a poltica
cientfica, mobilizando a populao para a participao nas decises sobre a alocao de
recursos de acordo com as prioridades na produo do saber.
51
Por outro lado, os veculos tm suas prprias agendas e sistemas de trabalho que podem no
ser compatveis com os interesses da rea da sade. Por interesses mercadolgicos, os meios
de comunicao podem promover ou potencializar comportamentos de risco, como o
consumo abusivo de bebidas alcolicas. Abordagens inadequadas da mdia sobre perigos, por
exemplo, utilizando o vis sensacionalista, podem causar dvidas no pblico ou mesmo
exacerbao do risco percebido (Rangel, 2007).
5
Utiliza-se a seguir o termo Jornalismo Cientfico, considerando-se que o Jornalismo em Sade est includo
nas definies e conceitos abordados.
52
Lima (1993) chama a ateno para o compromisso do jornalismo com a atualidade, o que
pode deixar em segundo plano objetivos educativos.
Melo (1982) defendeu que a funo social do jornalismo cientfico contribuir para a
superao dos muitos problemas que o povo enfrenta, por isso deve ser uma atividade
principalmente educativa, promovendo a iniciao dos jovens ao mundo do conhecimento e
de educao continuada dos adultos.
Para Beltro (1980), embora o jornalismo no tenha em sua base a funo educativa, a
imprensa pode assumir essa caracterstica quando apresenta informaes objetivas e
esclarecedoras sobre uma questo, permitindo comunidade agir com discernimento na
busca do progresso, da paz e da ordem justa. Para Bueno (1985), o jornalismo cientfico
cumpre seis funes bsicas: informativa; educativa; social; cultural; econmica e poltico-
ideolgica.
Para Bueno (1985), o jornalismo enquanto prtica educativa apresenta alguns problemas, tais
como: almanaquismo (e.g. tendncia a reduzir a informao cientfica mera curiosidade),
ausncia de uma mensagem didtica e positiva a falta de rigor cientfico, a tendncia ao
sensacionalismo e a superficialidade.
Reis (2002) destacou que durante muito tempo a divulgao cientfica no Brasil se limitou a
descrever aspectos interessantes e revolucionrios da cincia. O pesquisador criticava essa
abordagem e destacava que deveriam ser divulgados os princpios cientficos e metodologias
(a cincia como um processo), bem como a intensidade dos problemas sociais implcitos
nessa atividade. Zamboni (1997) afirma que a divulgao cientfica "privilegia, de modo
quase unnime, os resultados, suprimindo informaes sobre a metodologia utilizada, o que
no permite a avaliao crtica das pesquisas divulgadas pelo pblico e podemos supor que
transmite a ideia de que a cincia infalvel, produzindo sempre respostas finais e absolutas.
54
Groth (2007) definiu o jornalismo como uma cincia periodstica, uma cincia das culturas,
no uma mera tcnica. Os ramos dessa cincia so para ele a imprensa, o rdio, a televiso, o
cinema, a publicidade e tcnicas auxiliares, histria do jornalismo, legislao jornalstica,
empresas jornalsticas, anlise de audincia e anlise de contedo, sendo que a prtica deve
seguir quatro princpios bsicos: periodicidade, universalidade, atualidade e difuso.
deve ser uma novidade, e sim o que acontece no tempo presente. A difuso est relacionada
ao acesso do pblico informao. A difuso pode assumir um carter vertical (difuso
intensiva) em relao s camadas sociais que atinge, ou horizontal (difuso extensiva),
quando se considera as regies atendidas pela publicao. O autor considera essas
caractersticas inversamente proporcionais: quanto mais circula um jornal numa dada regio,
mais ele tende a concentra-se em determinadas classes sociais e vice-versa Groth (2007).
Para Medeiros (1996), a atualidade do jornalismo cientfico preenchida pelos fatos (eventos,
descobertas) ou pessoas (cientistas, tecnlogos, pesquisadores) diretamente ou indiretamente
relacionados com o momento presente, a universalidade contemplada pela abordagem dos
diferentes ramos do conhecimento cientfico, a periodicidade, pela manuteno do ritmo das
publicaes ou matrias, certamente antes em conformidade com o desenvolvimento peculiar
da cincia do que com o prprio ritmo de edificao dos veculos jornalsticos
(oportunidades, segundo Groth); e a caracterstica de difuso obtida com a circulao do
material pela coletividade qual se destina.
Segundo Bueno (2007), as notcias e reportagens sobre temas da sade, fluem na mdia
como peas de um quebra-cabea que nunca se completa, [...] se pudessem ser vistas
conjuntamente, indicariam, de imediato, contradies insanveis.
Larsson et al. (2003) avaliaram as mensagens sobre assuntos mdicos divulgadas pela
imprensa e identificaram nove obstculos para o aperfeioamento dos profissionais de
comunicao e dos textos: falta de tempo, espao e conhecimento, competio por audincia
e espao, dificuldades com a terminologia, problemas na identificao e uso de fontes de
informao, dificuldades com editores e aspectos da comercializao. Segundo a pesquisa,
os jornalistas concordam com a importncia da temtica, sendo que o caminho para a soluo
dos problemas o trabalho conjunto de profissionais de comunicao e da sade.
A percepo popular sobre os riscos sade subjetiva, com uma avaliao absoluta, as
pessoas esperam uma definio de segurana ou insegurana, sem incertezas (Slovic, 1987),
uma estimativa impossvel para cincia, seja pela prpria natureza probabilstica do risco,
como tambm pelas lacunas de conhecimento. Segundo a metodologia da comunicao de
risco, necessrio transparncia e proatividade na discusso sobre a magnitude e gravidade
da ocorrncia de danos, incluindo a abordagem das incertezas cientficas. A imprensa pode
colaborar com a divulgao de informaes, diferentes perspectivas e lacunas no
conhecimento, promovendo o debate sobre as opes de gerenciamento de riscos, entre os
setores governamentais, profissionais de sade e a sociedade.
58
1.6.Objetivos
Objetivo geral
Objetivos especficos
1.7.Justificativa
2. REVISO DA LITERATURA
Em 1919, uma nova matria do Washington Post, intitulada Was Jekyll and Hyde, abordou
novamente essa concepo ao descrever a histria de um criminoso com uma vida dupla e,
segundo um psiclogo, provavelmente sofrendo de Dementia Praecox. Assim, para
McNally (2007), o conceito popular equivocado de que a esquizofrenia resulta da diviso da
personalidade, uma dupla personalidade ou mltipla personalidade, teve sua origem, em
parte, na prpria comunidade cientfica, persistindo at a atualidade. Ironicamente esse
conceito popular errado se manteve de forma mais homognea do que o conceito mdico do
distrbio.
63
Os estudos das informaes sobre os distrbios mentais divulgadas pelos jornais tm utilizado
as metodologias da anlise de contedo e da anlise do discurso, sendo realizados por equipes
de pesquisas formadas por profissionais das reas de sade mental, de comunicao ou de
ambas as reas. So estudos transversais ou longitudinais, avaliando um ou mais jornais, em
formato padro e/ou tabloides. Os estudos avaliam a cobertura da imprensa dos distrbios
mentais em geral ou de um determinado distrbio.
Os objetivos principais dos estudos sobre a cobertura da imprensa a respeito dos distrbios
mentais tm sido descrever os temas abordados; identificar matrias que, intencionalmente ou
no, podem ter um carter prejudicial ou discriminatrio para os portadores; avaliar o impacto
das imagens divulgadas sobre as atitudes da populao em relao aos portadores de
distrbios mentais; avaliar o papel dos meios de comunicao de massa no desenvolvimento
e/ou aumento do estigma.
Os temas abordados pela imprensa com maior frequncia esto relacionados a crimes e
violncia e denncias sobre problemas do servio de sade mental. Wahl et al. (2003)
identificaram o tema em 30% de textos da imprensa norte-americana. Corrigan (2005)
identificou como o segundo tema mais recorrente o tratamento dos distrbios mentais. O
65
Noto et al. (2003) realizaram a anlise de contedo de 502 matrias publicadas no ano de
1998 em jornais e revistas brasileiras que abordavam o uso de substncias e as consequncias
para a sade, observando que elas no apresentaram o perfil epidemiolgico correto do
consumo de psicotrpicos no pas.
Slopen et al. (2007) compararam textos da imprensa sobre doenas mentais em crianas e
adultos, avaliando quais eram as informaes expostas e examinaram a ocorrncia de
elementos que indicassem uma abordagem responsvel. Concluram que as matrias focando
crianas continham informaes e abordagens mais adequadas, enquanto que os textos
relacionados s doenas mentais em adultos utilizavam linguagem e imagens estigmatizantes,
com frequncia associando doena mental e violncia.
Para comparar a qualidade das matrias que utilizavam termos relacionados esquizofrenia -
esquizofrenia, esquizofrnico(a) - publicadas pela imprensa do Reino Unido, em trs jornais
de formato padro e dois tabloides, nos anos de 1996 e 2005, Clement e Foster (2008)
67
Duckworth et al. (2003) compararam o nmero de textos com metforas utilizando os termos
schizophrenia, schizophrenic, schizo com o nmero de textos com o uso metafrico de
cncer, cancerous, em 7 jornais norte-americanos, 5 publicaes locais e 2 nacionais,
com as maiores tiragens, em 1996 e 1997. Observaram o uso metafrico em 1% dos textos
com os termos relacionados ao cncer e em 28% dos textos com termos relacionados
esquizofrenia, concluindo que a esquizofrenia est servindo para expressar idias atravs de
metforas, como foi a tuberculose no sculo XIX e o cncer no sculo XX. Os autores no
acreditam ser possvel ou necessrio eliminar o uso metafrico de uma doena na imprensa.
Entretanto, destacam que os psiquiatras devem trabalhar no esclarecimento de conceitos
equivocados disseminados em metforas.
Boke et al. 2007 analisaram textos em que um ou mais dos seguintes termos estava presente:
Schizophrenia, Schizophrenee Schizophrenic, verificando se o termo era usado no
68
sentido literal ou metafrico. Nos textos em que o uso era literal, o texto foi classificado
como positivo ou negativo de acordo com o contexto, foram contabilizados tambm os textos
sobre crimes e violncia. Os resultados indicaram que textos com referncia positiva ocorriam
a cada 12.2 dias e com carter negativo a cada 3.1 dias. Entre os 878 textos analisados, 44.1%
utilizavam o termo em uma metfora, o que segundo os autores explicaria a percepo
negativa da esquizofrenia no pas.
Klin e Lemish (2008) realizaram uma reviso da literatura sobre o papel dos meios de
comunicao de massa no desenvolvimento, manuteno ou reduo do estigma dos
distrbios mentais, observando que as descries dos transtornos e sobre os portadores so
distorcidas, devido a falta de acurcia, exageros, ou desinformao. Os distrbios mentais so
apresentados como peculiares, diferentes e perigosos, caracterizando que as mdias
perpetuam o estigma e a desinformao.
69
3. MTODO
70
Estudo transversal.
3.2.1Folha de S. Paulo
O jornal Folha de S.Paulo foi criado a partir da fuso de trs outros dirios, Folha da Manh,
Folha da Tarde e Folha da Noite, em 1960. A partir de 1962, Octavio Frias de Oliveira
modernizou a infraestrutura do jornal e reformulou o sistema de distribuio. Na dcada de
1970, Frias realizou reformas editoriais para buscar o pluralismo de opinies e ideias, abriu
espao para que lideranas da sociedade civil pudessem comentar a economia, os problemas
sociais e a poltica. A nova linha editorial agradou ao pblico, aumentando a tiragem de 200
mil para 300 mil exemplares por dia (Folha Online, 2009).
A partir de 1978, foi criado o Conselho Editorial, composto por jornalistas e no jornalistas,
que se renem mensalmente para avaliar a conjuntura poltica e econmica do pas, criticar o
desempenho jornalstico da Folha e recomendar linhas de ao editorial. Seus membros so
indicados pela direo da Empresa Folha da Manh S/A. Os integrantes da direo e da
redao tm direito a participar e opinar nas reunies (Arbex Junior, 2001).
Entre 1978 e 1986, o Conselho produziu seis documentos que constituram o que ficou
conhecido como Projeto Folha com definies sobre o conceito de informao para o jornal,
os temas sobre os quais se poderia opinar, o tipo de matrias que poderiam ser assinadas,
como a empresa geraria recursos e como o jornal deveria ser editado. A direo do jornal
explicitou que o objetivo das reformas era modernizar o jornal, para transform-lo em uma
empresa eficaz e profissionalizada, nos moldes do jornalismo praticado nos Estados Unidos
(Arbex Junior, 2001).
71
Atualmente a Folha de S.Paulo o jornal dirio com maior circulao no pas (Tabelas 1 e 2),
com uma mdia de 302 mil exemplares em dias teis e 365 mil aos domingos, sendo
igualmente o jornal mais lido pelos profissionais de mdia no pas, exceo cidade do Rio
de Janeiro, em que est em segundo lugar na preferncia (Associao Nacional de Jornais.
Maiores jornais do Brasil, 2009).
Tabela 2 - Principais jornais de acordo com a circulao, no ano de 2007 (Associao Nacional de
Jornais, 2009).
A seguir, foi realizada a triagem dos textos identificados (sem duplicaes), atravs da
aplicao dos critrios de incluso e excluso, com o registro dos motivos da excluso de
textos, resultando na definio final dos textos a serem includos no corpus analisado no
estudo.
74
Nas leituras flutuantes, foram observadas as seguintes utilizaes dos termos e as seguintes
temticas: textos que abordavam questes relacionadas sade (e.g. informaes sobre o
tratamento da esquizofrenia); notcias em que o personagem era supostamente um portador de
esquizofrenia (casos confirmados, casos suspeitos ou casos em que o indivduo tinha
experienciado um surto psictico); textos em que o termo era usado fora do contexto mdico,
com sentido metafrico; textos em que o termo era usado fora do contexto mdico, com o
sentido de distrbio mental ou sintoma (e.g. descrio de obras ficcionais com um
personagem que portador da esquizofrenia).
2) Utilizao popular dos termos: textos que utilizaram o termo fora do contexto mdico,
mantido seu sentido literal ou uso metafrico.
75
Inicialmente, foi realizada uma classificao preliminar dos textos em relao ao tema
principal: (1) Textos em que a esquizofrenia era o tema central; (2) Textos em que a
esquizofrenia era um tema secundrio.
Foi examinado o fac-simile da primeira pgina do dia em que cada texto foi publicado, para
se verificar se o texto gerou matria de primeira pgina. As matrias de primeira pgina
foram codificadas em matria central, matria principal e matria secundria, de acordo com
os tamanhos das fontes das manchetes e o posicionamento na pgina.
76
A anlise quantitativa foi realizada no programa estatstico Microsoft Office Excel 2007
para Windows, com o objetivo de calcular a frequncia das seguintes variveis para cada
categoria temtica: nmero de textos, nmero de matrias de capa (matria central, matria
principal e matria secundria), nmero de textos com fontes de informao citadas, nmero
de textos de acordo com o termo utilizado para se referir a portadores.
77
(1) Referncia literal esquizofrenia: quando o termo foi utilizado no texto com o sentido de
distrbio mental ou sintoma - mesmo que as caractersticas sugeridas pelo texto no
correspondessem descrio mdica.
e.g. [...] s brincava com amigos imaginrios. Acho que, se no tivesse sido atriz, teria sido
esquizofrnica
(2) Uso metafrico: quando o termo era empregado em uma comparao, cujo conectivo
comparativo estava subentendido, e o termo assumia um sentido conotativo, diferente do
habitual.
e.g. O Estado esquizofrnico mostra suas duas faces: o mau pagador de um lado e o
eficiente agente arrecadador de outro, [...]
Foram definidas categorias secundrias para os textos com referncias literais esquizofrenia
de acordo com a utilizao do termo (e.g. expresso pejorativa).
Foram extrados dos textos descries do distrbio ou notcias sobre o comportamento dos
portadores (e.g. portador descrito como assassino) para posteriormente ser desenvolvida a
sntese das caractersticas do distrbio sugeridas pelos textos.
78
As categorias secundrias dos textos com uso metafrico foram definidas de acordo com a
conotao da metfora:
Conotao positiva: quando o contexto favorvel imagem sugerida pela metfora (e.g.
falar com o comediante era ser seduzido por uma psicose de personalidades)
Conotao negativa quando a metfora apresentada como uma ideia desagradvel ou
usada em uma crtica negativa (e.g. mais estranho ainda a esquizofrenia nacional do
cmbio).
Conotao neutra quando no foi identificada uma conotao para a metfora no texto.
Exemplo:
[...] o PSDB no sofre da "esquizofrenia" de prometer uma coisa em campanha e fazer outra
no governo
Elementos comparados: esquizofrenia/ prometer uma coisa e fazer outra
Sentido inferido: contradio
79
O documento Healthy People 2010, elaborado pelo U.S. Department of Health and Human
Services (2000), sugere estratgias para a promoo de estilos de vida saudveis. No captulo
sobre comunicao em sade, o U.S. Department of Health and Human Services (2000)
define 11 atributos de uma comunicao efetiva direcionada para a populao.
No presente estudo, foram considerados quatro atributos definido pelo HHS (2000)
acurcia, equilbrio, confiabilidade, compreensibilidade - por estarem relacionados tambm
aos princpios bsicos do jornalismo cientfico: a busca ativa pelo contraditrio, o uso de
fontes de credibilidade, a adequao da linguagem e a traduo de conceitos.
O grupo de textos que utilizaram os termos no contexto mdico foi avaliado em relao aos
seguintes atributos definido pelo HHS (2000):
Para a anlise da qualidade das matrias publicadas pela imprensa do Reino Unido, Clement e
Foster (2008) desenvolveram indicadores de uma cobertura inadequada sobre os transtornos
mentais, baseados em princpios propostos pela National Union of Journalists (2004).
No presente trabalho, foi verificada a presena dos indicadores de uma cobertura inadequada
(National Union of Journalists, 2004; Clement e Foster, 2008) nos dois grupos de textos
(textos que utilizaram os termos no contexto mdico e textos com uso popular dos termos):
Foi considerado que o texto apresentava uma contextualizao para os casos de crimes e/ou
atos de violncia envolvendo portadores ou casos suspeitos quando eram apresentadas
informaes mdicas do indivduo envolvido na violncia (e.g. se o indivduo estava em
tratamento ou no), dados sobre o risco relativo do comportamento agressivo de portadores
em relao populao em geral (Walsh, 2002); informaes sobre a possibilidade do
tratamento da esquizofrenia.
81
Alm de lacunas na alfabetizao em sade metal, existem mitos populares que colaboram
para o estigma relacionado esquizofrenia.
Foi examinada a presena dos seguintes mitos populares, definidos por Hegner (2000), Social
Exclusion Unit (2004), e por Jones e Hayward (2004), nos dois grupos de textos (textos que
utilizaram os termos no contexto mdico e textos com uso popular dos termos):
4. ARTIGO CIENTFICO 1
ARTIGO CIENTFICO 1
Artigo submetido ao The Journal of Nervous and Mental Disease.
Maria Thereza Bonilha Dubugras, M.Sc., Doctorate student in the Collective Health Post-Graduation
Programme of the Preventive Medicine Department, Federal University of Sao Paulo. So Paulo,
Brazil.
Sara Evans-Lacko, Ph.d., Postdoctoral Research Fellow in the Department of Health Service and
Population Research at the Institute of Psychiatry, Kings College London. London, United Kingdom.
Jair de Jesus Mari, M.D., Ph.D., Professor, Department of Psychiatry, Federal University of Sao
Paulo. So Paulo, Brazil. Honorary Visiting Professor, Health Services and Population Research
Department, Institute of Psychiatry, Kings College London. London, United Kingdom.
84
ABSTRACT: Media is an important source of information about mental health for the public.
The current study analyzed the information about schizophrenia divulged by the largest
Brazilian newspaper. A Content Analysis examined articles on health and news involving
affected individuals or suspected cases. Articles were rated against indicators of poor quality
reporting and of effective health communication. The presence of myths was examined. The
search identified 687 articles, 75 of them fulfilled the inclusion/exclusion criteria and were
selected. The themes with the highest number of articles were: mental disorders and violence,
treatment and etiology. Three articles described social inclusion stories of affected individuals.
Coverage addressed the genetic factors, the drug-induced psychosis risk and the
antipsychotics benefits, which may contribute to stigma-reducing toward treatment. However,
articles divulged stigmatizing messages and the entire complexity of the disorder was not
discussed. Dangerousness was a common theme which may invalidate positive messages
about social inclusion.
INTRODUCTION
Media is an important source of information about mental health for the public and healthcare
professionals (Philo, 1994; Wahl, 2003) and can act as anti-stigma and anti-discrimination allies
(CSIP and Shift, 2008). However, previous studies about media coverage of mental disorders
indicated inaccurate and unfavorable depictions, focusing on risks of violence committed by
affected individuals (Chopra and Doody, 2007; Corrigan et al., 2005; CSIP/ Shift, 2006; Wahl,
1992) and stigmatizing language. The present study analyzed health articles and news involving
individuals with schizophrenia, published by the Brazilian daily newspaper Folha de S.Paulo,
between Jan 1st, 2007 and December 31st, 2008, to contextualize the disorder description among
the current scientific literature, and to determine whether newspaper information has potential
to contribute to public mental health literacy.
86
METHODS
Folha de S.Paulo (FSP) has the highest national circulation (280,972 daily and 329,278 on
Sunday). Readers are predominantly aged 30 and 49 years, of an upper-middle class
background, and 50% of them are men (Folha Online, 2009). FSP is a main source of
information for others Brazilian media, including television, the most popular communication
medium in the country (Azevedo, 2006). Independent, critical, non-partisan and pluralist
journalism is the premise of the newspaper according to its editorial guidelines. It was the
first communication vehicle in Brazil to adopt the role of ombudsman and to offer online
content for its readers (Folha, 2009).
The present study analyzed articles published in the daily print version of FSP, made online
for subscribers (available at http://www.uol.com.br/fsp). This database collects the entire
content of a daily edition; articles are available without any modification. . This database has
been used by most newspaper studies in Brazil (Vogt, 2010).
The electronic search was conducted in January, 2009, to identify all articles published
between Jan 1st, 2007 and December 31st, 2008, in which at least one of theses words was
presented: schizophrenia, schizophrenic(s), psychotic episode, psychosis and psychotic(s).
Inclusion criteria were: articles about health-related issues, which focused on or mentioned
schizophrenia or news involving individuals with a confirmed or unconfirmed diagnosis, or
that reportedly experienced a psychotic episode. Articles on fictional stories, and/or those that
used the term outside of the medical context (e.g. metaphorical use) were excluded.
A Content Analysis (Bardin, 1979) was performed, which comprised three stages: pre-
analysis, decoding (data classification) and analysis. For the pre-analysis, the corpus was
divided into two groups: (1) articles in which schizophrenia was the main theme and (2)
articles about other issues in which the disorder was a secondary theme. The articles were
displayed in a matrix, and the following data were extracted: title, date, newspaper section,
whether the story appears on the front page, type of article, sources, terms used when referring
to affected individuals and main event reported.
Primary content categories were defined according to the medical aspect focused on by the
articles main theme (i.e. diagnosis, etiology, pathogenesis, symptoms, treatment, prognosis,
epidemiological data, and personal experience of schizophrenia). Secondary content
categories were inductively developed according to the event reported (e.g. Committing an act
of violence news about violence allegedly committed by individuals with schizophrenia/
psychosis; Health care reorganization articles that report the process, achievement and/or
problems of the Brazilian psychiatric reform). The coding process was performed by one
researcher (MTBD). The inclusion/exclusion criteria and definition of each content category
were reviewed by all authors.
To verify the FSP emphasis on each primary category, front pages which have headlines of
the studied articles were analyzed and codified as main, primary or secondary headlines
according to the hierarchization of information, identified by the font size and by the location
on the page (Collaro, 2000).
Articles were categorized in terms of the presence or absence of the undermentioned common
myths about mental disorders: schizophrenia represents a split personality; is not a medical
condition, is a form of creativity/ inner journey, is completely attributable to genes, is a sign
of weak character; does not affect all people, affected individuals are completely disabled,
unable to make decisions and violent, there is no hope for them; being treated represents an
88
individuals failure/ weakness (Hegner, 2000; Jones and Hayward, 2004; Social Exclusion
Unit, 2004).
RESULTS
As described in Figure 1, the search identified a total of 687 articles, of those, 75 fulfilled the
inclusion/exclusion criteria and were selected, 43 were classified as articles in which
schizophrenia was the main theme and 32 as articles in which schizophrenia was a secondary
theme. The synthesis of the descriptive information about schizophrenia, presented by FSP, is
described in Box 1.
The primary categories identified were: mental disorders and violence (articles in which the
dominant theme was violence allegedly committed by a person with schizophrenia, with
unconfirmed diagnosis or that reportedly experienced a psychotic episode), treatment (the
dominant theme was related to medical care), general information (the dominant theme was
educational activity), etiology (the dominant theme were the etiologic factors), personal
experience of schizophrenia (stories involving affected individuals, excluding reports about
violence), epidemiology (the dominant theme was the disorder occurrence data), diagnosis and
classification (the dominant theme was related to the diagnosis system).
Schizophrenia or psychosis was the central theme of 43 articles (57.4%): 36 news stories, 3
opinion columns, 3 critical essays and 1 readers letter, sent by an advocacy organization.
Sources were mentioned in 31 articles, 58.1% used more than one; the majority consulted
universities and government agencies (e.g. Health Ministry). The categories are described in
Table 1. The mental disorders and violence category included 12 articles (12/43; 27.9%)
addressing 10 cases of violence: six cases of homicide, one case of serious aggression, one
case of peaceful disturbance, one case in which an affected individual confined his family at
home, and one in which the individual unintentionally exposed others to suffering. As
described in Figure 2, 83.3% of these articles were published in 2008. Ten articles addressed
violence committed during that period, published within one or two days after the event. The
suspects names were published in 11 articles. In only two cases, the trial already occurred,
nevertheless all articles identified suspects as guilty (A patient who suffers from
schizophrenia () stabbed his stepmother to death). According to FSP, schizophrenia was
89
confirmed in 3 cases (2 homicides); in one the individual committed the murder 3 days after
being discharged from hospital, a fact highlighted by the headline. In 4 articles in which the
diagnosis was unconfirmed, physicians who treated the individuals suggested the possible
condition (psychotic episode, psychotic behavior/disorder), in another three, relatives,
neighbors, police and/or doctors who had not directly followed the cases speculated about
schizophrenia or another mental disorder. Sub-themes identified were: causes of violent
behavior, concerns over the psychiatrists ability to predict and control aggressive behavior
and over the possibility that criminals claim to have a mental disorder to avoid prosecution.
Articles classified into the category treatment (10/43; 23%) emphasized the benefits of
antipsychotics, discussed health services, and described a new intervention - repetitive
transcranial magnetic stimulation (rTMS). Psychosocial interventions were not addressed.
Five articles criticized the psychiatric care adopted before the reform - due to individuals
isolation by the hospital-oriented system, to the use of electric shock (electroconvulsive
therapy - ECT) - and the present practice: psychiatrists have labels, this one is schizophrenic,
that one is manic-depressive, mood swings are diagnosed as bipolar disorder at the bat of
an eyelid and treated with stacks of new drugs, the side-effects of which are still not entirely
clear. Two articles focused on psychiatric reform, one reported achievements and the other
one, a letter from an advocacy organization, criticized it, due to delays in the implementation
of new community treatment centers.
Three positive stories (5.3%) involving individuals with schizophrenia were identified: two
focused artists life and one described an individual who was well-adjusted in her community.
Five articles addressed scientific research published by non-Brazilian journals: genetic factors
in the etiology of schizophrenia (2); risk factors (vitamin D deficiency and parental divorce)
(2); and animal models for treatment research (1).
Four articles had front page headlines: one belonging to the mental disorders and violence
category had a main front page headline; two categorized as treatment and one as general
information had secondary headlines (Figure 3).
90
Schizophrenia was quoted in 32 (43%) articles focusing issues related to: health (16 articles;
50%), psychology and behavior (4; 13%), literature (3; 9%), crimes (2; 6%), justice and public
security (2; 6%), education (2; 6%), science (1; 3.12%), media (1; 3%) and obituaries (1;
3.12%). Table 2 shows that the categories with the highest number of articles were etiology
(44%) and treatment (19%). Five articles mentioned research: causes of obesity/ side effects
of antipsychotics (1), mechanism of action of hallucinogenic substances / prospects in
schizophrenia treatment research (1), aging and chromosomal abnormalities/risk for
schizophrenia (1), medical use of marijuana/ drug-induced psychosis risk (1) and the
prevalence of celiac disease in Brazil/ its association with schizophrenia (1), the only study
conducted in Brazil.
Basic information on symptoms and genetic factors was accurate, but four articles associated
the disorder with multiple personalities. Lack of discussion about extrinsic etiological factors
and about a multidisciplinary approach to care limited the coverage. A balanced presentation
was identified in news about psychotropics (risks and benefits); but not in the article about
rTMS. Three articles about crimes speculated the possibility that the offender had a mental
disorder only on statements of police, neighbors or of psychiatrists not involved with the
cases, which may diminish their reliability. Statements from people with schizophrenia were
identified in 4 articles and/or from family in 8, totalizing 10/75 (13.3%). Medical terms were
not translated into layperson language, which may have hampered understandability. Of the
41 stories involving affected individuals, 46.3% used the term schizophrenic (15) or psychotic
(4); 3 (7.3%) utilized the expression suffered from or victims of schizophrenia and one (2.4%)
named them as madman.
article criticized the mystification of psychosis; six articles highlighted treatment benefits
and/or described social inclusion of individuals with schizophrenia.
DISCUSSION
Schizophrenia was the central theme in 43 articles and a secondary theme in 32 articles. The
categories with the highest number of articles of the group in which schizophrenia was the
main theme were mental disorders and violence (28%), and treatment (26%), and of the
group in which schizophrenia was a secondary theme, were etiology (44%), and treatment
(19%). Seventeen articles focused or mentioned violence allegedly committed by individuals
with schizophrenia/ psychosis. Articles about treatment addressed health service issues, risks
and benefits of antipsychotics, and future prospects. Genetic etiology and the risk of drug-
induced psychosis were highlighted. Myths were present in 6.7% of articles nevertheless,
another 9.3%, contradicted some myths, 56% of the stories involving affected individuals
used inadequate terms (e.g. schizophrenic, madman).
The association of mental disorders and violence has been a constant throughout history and
is culturally universal (Monahan, 1992), it is a determining factor of stigma (Link et al.,
1987) and is reinforced by the media (Philo, 1997). This linkage has been identified in
Brazilian public beliefs (Cirilo and Oliveira Filho, 2008; Monteiro et al., 2006; Peluso and
Blay, in press). Biological factors (genetics, complications in pre and post-natal periods, child
malnutrition and prefrontal cortex damage), social and environmental aspects, as well as, the
interaction between these factors are responsible for violent and antisocial behavior (Mendes
et al., 2009). There is no conclusive evidence that schizophrenia represents a considerable
risk factor for violence (Mulvey, 1994), when there are no comorbidities, drug abuse or acute
psychotic symptoms (Swanson et al., 1997; Wallace et al., 1998), and the risk of violence in
cases of comorbidity is similar to that for substance abuse without psychosis (Fazel et al.,
2009). Guides for journalists reporting on mental disorder (CSIP/ Shift, 2006; National Union
of Journalists, 2004; Schizophrenia Ireland, Lucia Foundation, 1999) propose that news about
violence perpetrated by affected individuals should include information to put the risk of
violence into perspective. For this purpose, Walsh et al. (2002) suggested that these articles
should present risk scales that describe the magnitude in relation to an individuals
community. FSP did not present such information. The FSP guide for journalists does not
permit criminal accusations before a definite trial, on the other hand, it argues that this
92
rule does not apply to acts in flagrante delicto or voluntary confessions'' (Folha de S. Paulo,
2001), hence supporting the studied articles which treat suspects as perpetrators. This should
be questioned as the media may set the tone for legal trials. News about criminal investigation
should include caveats such as it is probable, but not certain because it has not been proven
(Garcia, 1986). Research has shown that the public is not familiar with psychiatric
terminology (Peluso et al., 2008). It is possible to argue that, when faced with unknown terms
without explanations (e.g. psychosis, psychotic behavior) a FSP reader might associate
violence with mental disorders in general, without considering differences between the
disorders, degrees of severity, comorbidities, treatment adherence or other important
environmental factors. FSP articles expressed concern about the ability of psychiatry to assess
risk and control violent behavior. The community, legal professionals and the media expect
psychiatrists to predict and prevent violent behavior (Mason, 1998; Stark et al., 2004) an
unrealistic expectation (Hodgins et al., 1996), this should be carefully clarified. The Patients
Rights Guide (SES, 1999) states that medical information should be protected by professional
secrecy, consequently, should not be divulged in newspapers. Does reporting crimes
committed by affected individuals have a meaningful social purpose? The consequences of
the media exposing situations that are highly painful to affected individuals and their relatives
should be discussed. A single act of violence published by the media may have great
repercussions and lessen the efficacy of educational messages (Gattaz, 1999; Josef and Silva,
2003).
An East German study identified an increase in public willingness to seek help from a mental
health professional following an improvement in mental health literacy about the causes,
treatment and identification of schizophrenia symptoms (Angermeyer et al., 2009). The main
causes of schizophrenia attributed by the Brazilian public are related to psychosocial stress
(Peluso et al., 2008), the population belief that psychotropic medications can cause more
harm than benefit, consequently, lay people and psychologists are considered to be the most
useful sources of help (Peluso and Blay, 2009). FSP highlighted the role of genetic factors,
nevertheless extrinsic factors were merely mentioned and their importance was questioned,
limiting the approach. FSP addressed risks and benefits of psychotropics what may contribute
toward the diminishing of pharmacological treatment stigma, however, hospitalization and
ECT were described as harmful, similar to the public perception (Peluso and Blay, 2009).
Additionally, it could be argued that newspaper stories about the achievements of psychiatric
93
reform that criticize hospitalization, may suggest that outpatient treatment should replace
hospital service entirely. Nevertheless, guides about implementation of community care
emphasize the need for balance and integration of elements of community and hospital
services that can support people in crisis (Thornicroft et al., 2010). ECT was also perceived as
archaic; its use should be discussed with media professionals. The absence of information
about a multidisciplinary perspective of care in FSP indicates that research about
psychosocial interventions, e.g. family therapy (Mari and Streiner, 1994; Pharoah et al., 2006)
and cognitive behavioral therapy (Haddock et al., 1988), should be promoted among the
media and the public. Additionally, Brazilian scientific studies were poorly divulged.
FSP portrayed risk-related issues (e.g. psychotropic risk). People have a subjective perception
of risk and expect a definite and absolute answer: either it is safe or unsafe (Slovic, 1987) an
impossible estimation for science, both because of the probabilistic nature of risk, as well as
knowledge gaps. Risk communication emphasizes that popular concerns must be assessed,
including explanation about scientific uncertainty. The FSP discourse seems to yearn for a
single answer: psychological or genetic causes, psychotherapy or pharmacological treatment.
However, in regards to schizophrenia, these are mixed concepts and they include sub-concepts
which, sometimes, conflict with each other (Andreasen and Flaum, 1994; Elkis, 2000), thus
the challenge of the health communication about schizophrenia lies precisely in the
description of a multi-causal model, which needs a multi-disciplinary therapeutic approach to
an audience that may expect one final and absolute answer, without scientific uncertainty.
The three articles with positive stories published by FSP did not focus on treatment and
recovery; but, they did convey the message that with treatment it is possible to have good
quality of life. The stories did not criticize individuals characteristics (e.g. the musician
takes drugs to fight depression and has to make a constant effort in order to concentrate on
conversations. But when it comes to music, everything happens naturally) - this can be a
positive approach because it exemplifies strategies used by individuals, who, as defined by
Corin and Lauzon (1992), do not necessarily need to adopt normative social behavior.
Adjectives (e.g. schizophrenic) and the expressions suffer from and victim of schizophrenia
are inappropriate to identify individuals (Associao Americana de Psiquiatria, 1995;
Schizophrenia Ireland, Lucia Foundation, 1999) due to their dismissive and victimizing
character. Clement and Foster (2008) examined UK newspaper articles which contained the
94
term schizo addressing health and non-health related issues, and found that 64% used the
adjectival form and 14% used other stigmatized descriptors. Considering FSP health news
analyzed here and non-health related news (Dubugras et al., submitted for publication),
published in 2007 and 2008, adjectival use was similar (33/52; 63.4%) to UK study, while the
use of other stigmatized words was lower (2/52; 3.8%); nevertheless, it is not possible to say
that the Brazilian press language was more appropriate, because the UK study included 2
popular tabloids. Health professionals still use adjectives to describe individuals with
schizophrenia in the scientific literature, but this should be avoided, since the scientific
community is a source of information for the media. A few FSP articles (13.3%) presented
statements by individuals with schizophrenia and/or families, similar to the UK study
(Clement and Foster, 2008), seeking information from them and their experience should be
improved by media.
Studies indicate that the public associates schizophrenia with split personality or multiple
personality in different countries (Grausgruber et al., 2002; Schomerus et al., 2007). Similar
to what has been found here, other studies have identified this association in fictional literature
(Schomerus et al., 2007), TV and cinema (Hyler, 1988) frequently associated with violence
(Byrne, 2001) and in newspapers (Clement and Foster, 2008).
An important limitation of the study was the fact that the coding process was performed by a
single investigator (MTBD), without a reliability test of data extraction. Moreover, future
studies should investigate other media, with equal and different target audiences, and instead
of using specific search terms, should cover the whole newspaper to detect other terms that
may be used to refer to schizophrenia. It is also essential to determine individuals with
schizophrenia and their families perceptions about adequate media coverage. Despite these
limitations, this study provides an initial assessment of Brazilian newspaper coverage of
schizophrenia.
CONCLUSIONS
The press associates mental disorders with negative attributes such as unpredictability, danger,
criminality and isolation (Corrigan et al., 2005; Klin and Lemish, 2008). Crime news often
assumes that people with mental disorders are violent, especially those with schizophrenia,
and that the disorder is the main cause of crime and aggression, thus suggesting that patients
95
should be placed under control and that the healthcare system and its professionals are
ultimately responsible for violent incidents (Stark et al., 2004). Stories with a more positive
message (i.e. describing recovery) are rarely found in print (Wahl, 2003).
FSP presented information about the genetic factors, the risk of drug-induced psychosis and
the risks and benefits of psychotropic medication, which may contribute to a more favorable
perception of otherwise stigmatized interventions. Three stories of individuals with
schizophrenia integrated into society were divulged; however, news about crimes allegedly
committed by affected individuals surpassed positive stories both in number and emphasis.
Articles presented inappropriate language and stigmatizing messages. Additionally, results
suggest that the complexity of the disorder, its multifaceted etiology, individual differences
and therapeutic alternatives were not widely discussed. Dialogue among media and health
professionals, affected individuals and their families may improve media coverage about
schizophrenia.
REFERENCES
Angermeyer MC, Holzinger A, Matschinger H (2009) Mental health literacy and attitude
towards people with mental illness: A trend analysis based on population surveys in the
eastern part of Germany. Eur Psychiatry 24:225-32.
Baumann AE (2007) Stigmatization, social distance and exclusion because of mental illness:
The individual with mental illness as a stranger. Intl Rev Psychiatry 19:131-5.
Byrne P (2001) The butler(s) DID it - dissociative identity disorder in cinema. Medical
Humanities 27:26-9.
Chopra A, Doody GA (2007) Schizophrenia, an illness and a metaphor: analysis of the use of
the term schizophrenia in the UK national newspapers. J Roy Soc Med 100:423-6.
Collaro AC. Projeto grfico: teoria e prtica da diagramao. So Paulo: Summus, 2000.
Corin E, Lauzon G (1992) Positive withdrawal and the quest for meaning: the reconstruction
of experience among schizophrenics. Psychiatry 55:266-78.
Corrigan PW, Watson AC, Gracia G, Slopen N, Rasinski K, Hall LL (2005) Newspaper
stories as measures of structural stigma. Psychiatr Serv 56:551-6.
Corrigan PW, Watson AC (2003) Factors that explain how policy makers distribute resources
to mental health services. Psychiatr Serv 54:5017.
CSIP, Shift (2006) Mind over matter. Improving the reporting of mental health. London: the
Sainsbury Centre for Mental Health. Retrieved January 15, 2007, from
http://www.shift.org.uk
97
CSIP, Shift (2008) Mind over Matter 2. Shift Media Survey: Summary Report. Institute of
Psychiatry, Kings College: London. Retrieved September 2, 2009, from
http://kc.csip.org.uk/viewdocument.php?action=viewdoxepid=0edoc=38248egrp=584
Eagles JM, Carson DP, Begg A, Naji SA (2003) Suicide prevention: a study of patients'
views. Br J Psychiatr 182:261-5.
Elkis H (2000) A evoluo do conceito de esquizofrenia neste sculo. Rev Bras Psiquiatria
22(Suppl. 1):23-6.
Fazel S, Gulati G, Linsell L, Geddes JR, Grann M (2009) Schizophrenia and violence:
systematic review and meta-analysis. Plo S Med [online] 8. Retrieved September 11, 2009,
from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2718581/pdf/pmed.1000120.pdf
Folha Online (2009) Tudo sobre a Folha. Retrieved January 15, 2009 from
http://www1.folha.uol.com.br/folha/80anos/
Gattaz WF (1999) Violncia e doena mental: fato ou fico? Rev. Bras. Psiquiatr 21(4).
Retrieved June 11,2007 from
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-
44461999000400005&lng=en
Hegner RE (2000) Dispelling the myths and stigma of mental illness: the Surgeon Generals
report on mental health. Issue Brief Natl Health Policy Forum 14:1-7.
Hodgins S, Mednick SA, Brennan PA, Schulsinger F, Engberg M (1996) Mental disorder and
crime. Evidence from a Danish birth cohort. Arch Gen Psychiatr 53:489-96.
Hyler SE (1998) DSM-III at the cinema: madness in the movies. Compr Psychiatr 29:195-
206.
Jones S, Hayward P (2004) Coping with schizophrenia: A Guide for Patients, Families and
Carers. Oxford: Oneworld Publications.
Josef F, Silva JAR (2003) Doena mental e comportamento violento: novas evidncias da
pesquisa. J Bras Psiquiatr 52:127-35.
Klin A, Lemish D (2008) Mental disorders stigma in the media: review of studies on
production, content, and influences. J Health Comm 13: 434-49.
Leff J, Warner R (2006) Incluso social de pessoas com doenas mentais. Coimbra:
Almedina.
Link BG, Cullen FT, Frank J, Wozniak JF (1987) The social rejection of former mental
patients: understanding why labels matter. Am J Sociol 92:1461-1500.
Mari JJ, Streiner D (1994) An overview of family interventions and relapse on schizophrenia:
meta-analysis of research findings. Psychological Medicine 24:565-78.
Mason T (1998) Tarasoff liability: its impact for working with patients who threaten others.
Int J Nurs Stud 35:109-14.
Mendes DD, Mari JJ, Singer M, Barros GM, Mello AF (2009) Estudo de reviso dos fatores
biolgicos, sociais e ambientais associados com o comportamento agressivo. Rev Bras
Psiquiatria 31(Suppl. 2):77-85.
Monahan J (1992) A terror to their neighbors: beliefs about mental disorder and violence in
historical and cultural perspective. Bulletin of the American Academy of Psychiatry e the
Law 20:191-5.
Monteiro VBM, Santos JQ, Martin D (2006) Patients relatives delayed help seeking after a
first psychotic episode. Rev Bras Psiquiatria 28:104-10.
Mulvey EP (1994) Assessing the evidence of a link between mental illness and violence. H &
CP 45:663-8.
National Union of Journalists (2004) The reporting of mental health and suicide by the
media. A practical guide for journalists. Scotland: National Union of Journalists.
Retrieved June 22, 2007, from
http://iasp.info/pdf/task_forces/Scotland_Reporting_Media.pdf
Peluso ETP, Peres CA, Blay SL (2008) Public conceptions of schizophrenia in urban Brazil.
Soc Psychiatr Psychiatr Epidemiol 43:792-9.
Peluso ETP, Blay SL (2009) Public beliefs about the treatment of schizophrenia and
depression in Brazil. Int J Soc Psychiatr 5:16-27.
Peluso ETP, Blay SL (in press). Public stigma and schizophrenia in So Paulo city. Rev Bras
Psiquiatria [online] Retrieved May 23, 2010 from
http://www.scielo.br/pdf/rbp/2010nahead/aop0410.pdf
Penn DL, Kohlmaier JR, Corriganc PW (2000) Interpersonal factors contributing to the
stigma of schizophrenia: social skills, perceived attractiveness, and symptoms. Schizophr
Res 45:37-45.
Pharoah F, Mari JJ, Rathbone J, Wong W (2006) Family intervention for schizophrenia.
Cochrane Database of Systematic Reviews. 4, Art. N: CD000088.
100
Philo G (1997) Changing media representations of mental health. Psychiatr Bull 21:171-2.
Schizophrenia Ireland, Lucia Foundation (1999) Guide for Journalists and Broadcasters.
Reporting on Schizophrenia. Retrieved March 21, 2007 from:
http://www.sirl.ie/other/repository_docs/82.pdf
SES (Secretaria de Estado de Sade do Estado de So Paulo). (1999). Cartilha dos Direitos
do Paciente do SUS. So Paulo: Secretaria de Estado de Sade do Estado de So Paulo.
Retrieved Aug 23, 2005 from http://www.saude.sp.gov.br.guiacidadao
Social Exclusion Unit (2004) Mental Health and Social Exclusion. London: Office of the
Deputy Prime Minister.
Sosowsky L (1980) Explaining the increased arrest rate among mental patients: A cautionary
note. Am J Soc Psychiatr 137:1602-5.
Thornicroft G (2006) Shunned. Discrimination against people with mental illness. Oxford:
Oxford University Press.
101
Thornicroft G, Alem A, Santos RAD, Barley E, Drake RE, Gregorio G, et al. (2010) WPA
guidance on steps, obstacles and mistakes to avoid in the implementation of community
mental health care. World Psychiatr 9:67-77.
U.S. Department of Health and Human Services (2000) Healthy People 2010: Understanding
and Improving Health (2nd ed). Washington, DC: U.S. Government Printing Office.Vogt,
Knobel M, Castelfranchi Y, Evangelista R, Gartner V. (2010) Sapo: Building a barometer
of science and technology in the media.
http://143.107.80.179/files/SAPO_RoyalSoc_en.pdf
Wahl OF (1992) Mass media images of mental illness: a review of the literature. J Comm
Psychology 20:343-52.
Wahl OF (1996) Brief reports. Schizophrenia in the news. Psychiatr Rehabil J 20:51-4.
Wahl OF (2003) News media portrayal of mental illness. Implications for public policy. Am
Behav Sci 46:1594-1600.
Walsh E, Buchanan A, Fahy T (2002) Violence and schizophrenia: examining the evidence.
Br J Psychiatry 180:490-5.
102
Table 1- Primary and secondary categories of articles in which schizophrenia was the main theme,
published by the newspaper Folha de S.Paulo, between 2007 and 2008.
Figure 2 Distribution of thematic categories of articles in which schizophrenia was the main
theme, according to the year under study.
105
Table 2 Primary and secondary categories of articles in which schizophrenia was a secondary
theme, published by the newspaper Folha de S.Paulo, between 2007 and 2008.
(1)
(2)
Figure 3 - Examples of front page headlines identified: (1) Main headline: You gave me only one
option, says South-Korean discussion about the mental health of the Virginia Tech massacre
gunman; (2) Secondary headline: Woman meets her family after 42 years of hospitalization article
about health service reorganization.
Note. Headlines were codified according to the location where the story starts on the page and by the
font size - (1) Main headline: it is localized on the first and second quadrants and font size of headline
is the with intermediated size among others headline; (2) Secondary headline: it is localized on the
third quadrant and presented in a smaller sized font compared to the rest of the page).
107
Box 1 - Synthesis on the diseases description according to the articles published during 2007 and
2008, in Folha de S. Paulo.
Occurrence: Schizophrenia is considered one of the most devastating mental disorders (FSP,
08/02/2007). It affects approximately 1% of the Brazilian population (FSP, 08/02/2007) and,
together with the delirious and schizotypal disorders, it is responsible for making 4.04 in every 10
thousand inhabitants take a leave of absent from work every year (FSP, 02/11/07).
Etiology: The causes of schizophrenia are little understood by science (FSP, 10/09/2008). Four
articles discussed the role played by the genetic component in the etiology of schizophrenia: they
are genetic mistakes (FSP, 10/19/07), mutations in a set of genes related to the brains
development (FSP, 03/28/08). The use of substances (9 articles), vitamin D deficiency (2 articles)
and family disaggregation (2 articles) were presented as risk factors for schizophrenia.
Symptomatology: Symptoms include hallucinations, twisted thinking and distorted emotions
(FSP, 07/31/2008), schizophrenia may lead to the fragmentation of the patients personality, as
well as make the patient lose touch with reality (FSP, 02/04/08). Affected individuals may
experience a number of incidents ranging from a simple anxiety crisis to an acute psychosis
episode requiring specialized care (FSP, 05/24/08).
Treatment and prognosis: Second generation antipsychotics allow a person suffering from a
psychiatric disease to control its painful symptoms [...], but can result in weight gain, diabetes,
increased cholesterol and even premature death due to a heart attack if the patient does not
receive proper follow-up (FSP, 03/30/07). The prognosis of substance-induced psychosis was
portrayed as unfavorable: playing with drugs may cause irreversible damages (FSP, 11/23/08).
Psychiatry: Some psychiatrists are only concerned with what happens to a patient from the neck
up, says Newcomer (FSP, 11/03/07). Psychiatrists have labels, this one is schizophrenic, that
one is manic-depressive (FSP, 12/05/08). These days, mood swings are diagnosed as bipolar
disorder at the bat of an eyelid and treated with stacks of new drugs, the side-effects of which are
still not entirely clear (FSP, 04/25/08).
Personal experience of schizophrenia: He was diagnosed as schizophrenic in the 1970s; the
musician takes drugs to fight depression and has to make a constant effort in order to concentrate
on conversations. But when it comes to music, everything happens naturally (FSP,
03/13/07).Genetics can be cruel. My own son may have been one of its victims [...] Rufus is
incapable of living an independent life because of schizophrenia (FSP, 10/19/07).
108
5. ARTIGO CIENTFICO 2
"Ela no uma serial killer, mas uma esquizofrnica, quer ser a Donatela, ter
tudo o que ela tem" Joo Emanuel Carneiro [comentrio de um autor de novela de
televiso sobre a vil que criou para a trama] (Folha de S.Paulo 07/08/2008).
109
ARTIGO CIENTFICO 2
Artigo submetido ao Psychiatric Services.
Maria Thereza Dubugras, M.Sc., Doctorate student in the Collective Health Post-Graduation
Programme of the Preventive Medicine Department, Universidade Federal de So Paulo.
Sara Evans-Lacko, Ph.d., Postdoctoral Research Fellow in the Department of Health Service
and Population Research at the Institute of Psychiatry, Kings College London.
Jair de Jesus Mari, M.D., Ph.D., Professor, Department of Psychiatry, Universidade Federal
de So Paulo. Honorary Visiting Professor, Health Services and Population Research
Department, Institute of Psychiatry, Kings College.
110
ABSTRACT
Objective: To analyze the popular use of schizophrenia-related terms in articles about non-
health issues of daily newspaper, Folha de S.Paulo(FSP), during 2007 and 2008.
Methods: Cross-sectional analysis of newspaper content, popular meanings attributed to
medicals terms and of schizophrenia features suggested by the articles. An electronic search
utilized the terms: schizophrenia, schizophrenic, psychotic episode, psychosis, psychotic.
Articles were classified as (1) literal reference to the disorder or (2) metaphoric usage.
Secondary categories were inferred from articles with literal references according to the terms
contextual usage, and from articles with metaphors, according to metaphor connotation. The
metaphorical meaning was defined by the element compared to the term by the
metaphorization. Articles were rated against poor quality reporting indicators and the
presence of myths was examined.
Results: A total of 687 articles were identified, 99 of them were duplicates and 444 did not
meet inclusion/exclusion criteria, resulting in a total of 144 articles included in the analysis
(69 literal references and 75 used the term metaphorically). Literal references were identified
in fictional reviews, disorder description (including non pathological features described as
schizophrenia), pejorative labels, and humoristic expressions or occurred incidentally. The
metaphoric meanings identified included: contradiction, splitting/ multiplicity, lack of
meaning and conflict, 80% of them with a negative connotation.
Conclusion: FSP associated schizophrenia and violence or creativity, divulgated myths and
stigmatized images. These results emphasize the necessity of information exchange between
journalists, mental health professionals and advocacy organizations about the disorder and
about the negative consequences of stigma.
KEY WORDS: Mental Illness, Schizophrenia, Journalism, Print Media.
111
INTRODUCTION
In 1911, Eugen Bleuler published the monograph The diagnosis of dementia praecox: the
group of schizophrenias, in which he defined new concepts for dementia praecox and
suggested the term schizophrenien to describe a group of disorders. Schizophrene was a term
derived from the Greek words schizo [split] and phrene [mind] that pointed to one of the
major characteristics of these disorders, according to Bleuler: the splitting of psychic
functioning.
The Washington Post published five years later an interview with the psychologist Stanley
Hall, who reinforced the use of the term as splitting of the personality[1]. To describe his
attempt to reconcile contradictory feelings about Germany during the First World War, Hall
affirmed, metaphorically, to the journalist that he had developed schizophrenia or a split
soul, explaining that schizophrenia was a term often used by psychologists to describe a
split mind, and the Jekyll-Hyde personality is one of these types [of disorder], associating
schizophrenia to a double personality, as experienced by Dr Jekyll, in the Stevenson horror
novel. In 1919, this idea appeared in another article in the Washington Post, entitled Was
Jekyll and Hyde, about a man with a secret criminal life who, according to a psychologist,
was "probably suffering from dementia praecox". The misconception that schizophrenia
involves a split personality seems to be derived from health professionals attempts to explain
the disorder to the public; ironically, this popular idea has been more stable over the years
than the scientific concept [1]. Studies indicate that the public associates schizophrenia with a
split personality or multiple personality across different countries, e.g. Germany [2],
Austria [3], Canada [4], UK [5]. This concept is present in fictional literature [2], TV shows
and cinema [6], where there is confusion between schizophrenia and dissociative identity
disorder, frequently associated with violence [7], and in newspapers [8]. Media perpetuate
this and other myths related to schizophrenia.
Previous studies on the portrayal of mental illness (MI) in the media have demonstrated an
emphasis on crimes committed by individuals with MI, news about the treatment of mental
disorders, and on negative characteristics, such as unpredictability, dangerousness, and
112
isolation [9-13]. There is also evidence that psychiatric terms are also used outside of the
medical context through derogatory expressions and metaphors [8,14-16].
Analysis of newspaper content is significant because the media is the publics primary source
of information about MI, public attitudes are more likely to be affected by media than by
direct contact with individuals with MI [17], and mass media can influence mental health
policy [18]. Dissemination of misconceptions and stigmatized images by the media
contributes to negative attitudes toward MI and psychiatric treatments, impedes recognition
of symptoms, and reduces help-seeking [19]. Psychiatrists should be aware that individuals
with schizophrenia, their care-givers and the public may have their own meanings for medical
terms [8]. The present study analyzed the popular use of terms related to schizophrenia and
the information divulgated by the largest Brazilian daily newspaper, among articles about
non-health related issues, during 2007 and 2008.
METHODS
Folha de So Paulo (FSP) is the first newspaper in national circulation (280,972 daily and
329,278 on Sunday). Readers are predominantly aged 30 to 49, have attended college, and 50%
of them are men [20]. An electronic search of the FSP database was performed between January
1st, 2007 and December 31st, 2008, using the following terms: schizophrenia, schizophrenic,
psychotic episode, psychosis, psychotic. Articles which dealt with non-health related issues
(e.g. arts articles) were included. Exclusion criteria were: articles about health issues, news
involving people with schizophrenia or suspected cases, or those in the TV guide section.
First, articles were classified according to the general meaning of the terms identified, into two
primary categories: (1) literal reference to the disorder articles in which the term had the
meaning of mental disorder/symptom, and (2) metaphoric usage i.e. an implied comparison of
two dissimilar objects without using the words as or like (e.g. fashion is schizophrenic) [21].
Secondary categories were developed inductively from the articles classified as literal
reference according to the contextual usage of terms (e.g. pejorative label). Events reported
(e.g. violence) and descriptions of disorder were coded into broader categories on
schizophrenia features suggested by these articles. Subcategories were defined from the
articles with metaphoric usage based on metaphor connotation (i.e. implied value judgment):
(1) positive association - when the context was favorable according to the metaphoric image
113
(e.g. to speak with the comedian (...) was to be seduced by a euphoric psychosis of
personalities), (2) negative - when the metaphor was presented as an unpleasant idea or a
negative critique (e.g. more stranger than that is the national schizophrenia related to
exchange) or (3) neutral - no connotation was identified. Features of schizophrenia suggested
by these articles were defined according to metaphors contextual meaning. The method used
for metaphors analysis was adapted from a previous study [22]: any words or phrases that
were used as equivalent adjectives or were closely linked in the text were recorded and
synthesized into one word (e.g.1: The schizophrenic governor shows its two faces
equivalent: two faces; e.g.2: PSDB does not suffer from schizophrenia`, it does not promise
one thing during campaign and do another thing during govern idea inferred:
contradiction). Metaphors meaning were coded into broader categories on features of
schizophrenia suggested by these articles.
Articles were rated against indicators of poor quality reporting (metaphoric use of
schizophrenia terms, use of adjectival form of the medical term, i.e. schizophrenic, psychotic,
or other stigmatizing descriptors, e.g. madman, to describe persons with diagnosed or
imputed schizophrenia/psychosis [8, 23]) and the presence of common myths about MI was
examined (Schizophrenia involves a split personality. MI is not a medical condition, is
similar to learning disorders, a form of creative imagination/ inner journey, does not affect all
people, is completely attributable to genes, or is a sign of weak character. Affected
individuals are completely disabled, unable to make decisions and violent, there is no hope
for them. If you have a MI, you can will it away, and being treated represents an individuals
failure/ weakness) [24-27].
RESULTS
As described in Figure 1, a total of 687 articles were identified based on the search terms, 99
of them were duplicates and 444 did not meet inclusion criteria, resulting in a total of 144
articles included in the analysis. Of those included, 69 were classified as literal reference to
the disorder and 75 were classified as metaphoric usage. The majority of the articles
addressed arts & entertainment (79), politics (35), economy (11) and sports (9).
114
As showed in Table 1, the secondary categories identified were: (1) Fictional plots -
descriptions of movies or books with characters with schizophrenia or whose behavior was
named as schizophrenic/psychotic (in 38% of these, the character was violent/criminal), (2)
Imputed schizophrenia - descriptions about schizophrenic features (e.g. I do not interpret
fictional characters, because I am not a schizophrenic person), (3) Pejorative label terms
were used to offend or criticize a person that does not have a MI (e.g. Paes called Lula
psychotic and a gang ringleader), (4) Humoristic/ironic expression association with comic
or ridiculous situations (with the World Cup, men are on the verge of a psychotic episode), (5)
Incidental when the term appeared in a fictional story title, without additional information
(together with Hitchcock, he made the storyboard of Psycho).
The majority of metaphors were identified in articles written by journalists (26; 35%) and in
statements of artists (18; 24%), politicians (18; 24%) and economists (6; 8%). Metaphors
attributed schizophrenia to organizations (e.g. government), groups of individuals (e.g.
consumers), and process (e.g. economic evaluation).
The terms which were used as metaphors were: schizophrenic (38; 50.6%), schizophrenia
(26; 34.6%), psychosis (5; 6.6%), psychotic (2; 2.6%), and psychotic episode (4; 5.3%).
Metaphors using schizophrenia and schizophrenic had a negative connotation in 51 articles
(51/75; 68%), a positive connotation in 12 (12/75; 16%) and neutral connotation in 1 (1/75;
1.3%). The negative metaphors were: contradiction (24), incoherence (8), splitting/
multiplicity (8), oscillation (4), unrealistic (2), withdrawal (1), and indecision (1). The
meaning could not be defined in the 3 remaining articles with negative metaphors. The
115
positive metaphors were: splitting/ multiplicity (5), peculiarity (3); aggression (1),
intermediate state (1), great creativity (1), and transformation (1). The meaning of the neutral
metaphor was splitting/ multiplicity (1). Metaphors with psychosis/ psychotic had a negative
connotation in 5 (5/75; 6.7%) articles, whose meanings were aggression, contradiction,
unreality, and obsession (there was no information for the analysis of one of these
metaphors), and a positive connotation in 2 (2/75; 2.6%), whose meaning was splitting/
multiplicity and boldness. All metaphors with psychotic episode (4/75; 5.4%) had a negative
connotation, meaning obsession, authoritarianism, contradiction and unrealistic. The
metaphors with a positive connotation were identified in articles about artistic creation (14).
Articles suggested general features (e.g. unreal perceptions) and features that characterized
individuals as aggressive/authoritarian (23), creative rebellious (18) or incapable/vulnerable
individuals (5) (Table 1).
The indicators of poor reporting identified were: metaphorical usage (75/144; 52%), use of
the adjectival form (31/42; 73%) or other stigmatizing descriptors (7/42; 16.7%) (e.g.
madman, monster) in articles that quoted individuals with schizophrenia or used the terms to
describe individuals that did not have a MI.
DISCUSSION
Schizophrenia was the main or a secondary theme of 144 articles, 69 of them made literal
reference to the disorder and 75 used the term as a metaphor. The literal references were
identified in fictions reviews (in 38% of them, a character with MI was violent), descriptions
about features of schizophrenia (including non pathological features described as
schizophrenia), pejorative labels, and in comic expressions or incidental occurrences. In
116
Although no article affirmed that all persons with MI are violent, 14 articles discussed an
association between the disorder and violence without contextualizing the risk. This
association has been identified in FSP health news about schizophrenia published in 2007 and
2008 [28] and other studies [8,29,30].The belief that MI are associated with violence has been
a constant throughout history and culturally universal [31], and is a determining factor of
stigma [32]. This perception was identified on Brazilian surveys with relatives and mental
health care consumers [33,34]. Fictional stories may reinforce this popular belief.
The lack of disorder specification, observed here for psychosis/ psychotic episode, has also
been detected in USA newspapers [35]. One possible negative consequence of this is that the
public evaluates topics, such as prognosis and violence, without considering the differences
between disorders, degrees of severity, comorbidities or adherence to treatment.
The emphasis on psychological causes of schizophrenia identified here has also been
observed in other studies with the Brazilian public [36] and in other countries [37]. FSP
articles on health issues about schizophrenia published in 2007 and 2008 [28] highlighted the
risk of drug-induced psychosis and genetic factors, but did not describe the multi-causal
model. This divergence may result from editorial segmentation. FSP articles on health quoted
medical sources, recent genetic research or the risk associated with substance use, whereas
FSP articles analyzed here presented fictions and seemed to be influenced by and project
popular beliefs. Movie plots frequently attribute MI to psychological factors [38]. The
problem of this cinema representation is that it uses to be linked to negative criticisms of
pharmacological treatment.
117
The association of false features of a disorder through the use of metaphors is a reflection and
reinforcement of popular beliefs [39], and can contribute to stigma. The metaphors identified
in this study such as contradiction, splitting/ multiplicity (Figure 2) and oscillation were
similar to those observed in newspapers from the UK and USA [8, 16]. The meanings of
multiplicity, oscillation, aggression and withdrawal may be linked to the popular perception
that individuals with schizophrenia are unpredictable, dangerous and antisocial; ideas which
were also identified in another study [12].
One difference between the present results and previous studies is that metaphors with a
positive connotation were found (e.g. great creativity) and the meanings of splitting/
multiplicity and aggression were identified with both negative and positive connotation, when
related to artistic creation. The association between MI and creativity/ genius may be
inadequate to combat stigma because it may suggest that only individuals with extraordinary
talents will be accepted and valued by society [40] or that medical treatment is not necessary.
The metaphoric meaning of multiplicity also had a neutral connotation in that it is a feature of
humankind, similar to the idea that there is no mental normality, which was observed in a
different study about public perceptions in Brazil [41].
The use of the adjectives or other stigmatized word to describe individuals was lower on FSP
news on health that addressed schizophrenia, respectively 19 (46.34%) and 1 (madman)
(2.43%) [28]. Health related articles were also more likely to discuss relevant information
about the disorder [28], however they did not always not clarify the misconceptions found
here, because popular beliefs are not exclusively influenced by information based on medical
sources [17,42].
Other studies investigating media have included only schizophrenia and schizophrenic as
search terms, and analyzed coverage about non-health related issues and about health related
issues together [14-16,43]. When applying these terms only, FSP published 48 news on health
[28] and 91 on non-health issues, 46% of them (64/139) used terms in metaphors; 63.46%
(33/52) used the adjectival and 3.84% (2/52) used other stigmatizing descriptor. The
metaphor usage was similar to Turkey newspapers (44.1%) [43], and higher than UK (11-
23%) [15,8], USA (28%) [16] and Germany (31%) [14]. The description of individuals with
the adjectival was similar to UK newspapers (64%) [8], the other stigmatizing descriptor
usage was lower than UK (14%) [8].
118
One study about cancer and AIDS metaphors [39] proposed that stigmatized illnesses are
those that are feared, due to ignorance about their etiology and to the idea of no potential for
effective treatment. Results found here suggest that there should be more divulgation of the
multi-causal model of schizophrenia to the public. The public expects that treatments are
synonymous with cures, so educational campaigns should continue to emphasize that control
of symptoms, can also lead to improved quality of life for persons with schizophrenia.
FSP audience is upper and middle class, so this study is not representative of all Brazilian
readership, nevertheless FSP news are also divulgated to broader audience through opinion
leaders and when influence TV agenda (the most popular media in Brazil) [45]. Future studies
should investigate other media, including those directed at different socioeconomic classes
and detect other terms that may be used to name schizophrenia. Despite these limitations, this
study provides an initial assessment of information about schizophrenia presented by
Brazilian print media.
The analysis of messages and images delivered by the media is a way to access the popular
culture in which individuals with schizophrenia are inserted [19]. Results may contribute with
information on public knowledge and beliefs to educational programs planning..
Edgar Allan Poe wrote that it "is not yet settled, whether madness is or is not the loftiest
intelligence, and at same time stated that who dream by day are cognizant of many things
which escape those who dream only by night. The articles analyzed here expressed this
popular doubt: whether individuals with schizophrenia are completely disabled or creative
free spirits.
119
FSP articles divulgated myths about MI and stigmatizing messages. One of the most
significant factors contributing toward public stigma, the assumption that persons with
schizophrenia are violent, was highlighted in FSP. Schizophrenia related terms were used to
name non-pathological features and were applied in pejorative, comic and metaphorical
expressions. Concepts about MI which emerged from this kind of portrayal are not new; on
the contrary, they perpetuate discriminatory ideas which may exacerbate negative public
perceptions. These results emphasize the necessity of information exchange between
journalists, mental health professionals and advocacy organizations about the disorder and
about the negative consequences of stigma.
REFERENCES
1.McNally K: Schizophrenia as split personality/Jekyll and Hyde: the origins of the informal
usage in the English language. Journal of the History of the Behavioral Sciences 1: 69-79,
2007
2.Schomerus G, Kenzin D, Borsche J, et al: The association of schizophrenia with split
personality is not an ubiquitous phenomenon. Soc Psychiatry Psychiatr Epidemiol
42:780-786, 2007
3.Grausgruber A, Katschnig H, Meise U, et al: Einstellung der osterreichischen
Bevolkerung zu Schizophrenie [Attitudes of the general population towards
schizophrenia in Austria]. Neuropsychiatrie 16:54-67, 2002
4.Stuart H, Arboleda-Florez J: Community attitudes toward people with schizophrenia. Can J
Psychiatry 46:245-252, 2001
5.Furnham A, Chan E: Lay theories of schizophrenia. Soc Psychiatry Epidemiol 39: 543-552,
2004
6.Hyler SE: DSM-III at the cinema: Madness in the movies. Comprehensive Psychiatry
2:195-206, 1988
7.Byrne P: The butler(s) DID it - dissociative identity disorder in cinema. J Med Ethics:
Medical Humanities 27: 26-29, 2001
8.Clement S, Foster N: Newspaper reporting on schizophrenia: A content analysis of five
national newspapers at two time points. Schizophrenia Research 98: 178-183, 2008
9.Nairn R, Coverdale J, Claasen D: From source material to news history in New Zealand
print media: a prospective study of the stigmatizing process in depicting mental illness.
Aust N Z J Psychiatry 35: 654-659, 2001
120
26.Jones S, Hayward P. Coping with Schizophrenia: A Guide for Patients, Families and
Carers. Oxford: Oneworld Publications; 2004
27.Hegner RE: Dispelling the myths and stigma of mental illness: the Surgeon Generals
report on mental health. Issue Brief Natl Health Policy Forum 2000;(754):1-7
28.Dubugras MTB, Evans-Lacko S, Mari JJ: A Two-Year Cross-sectional Study on the
Information Disseminated about Schizophrenia in a Prestigious Daily Brazilian
Newspaper (submitted unpublished manuscript, 2010)
29.Shain, R, Phillips J: The Stigma of Mental Illness: Labeling and Stereotyping in the News,
in Risky Business: Communicating Issues of Science, Risk, and Public Policy. Edited by
Wilkins L, Patterson P. New York, Greenwood Press, 1991
30.Wahl O: Brief reports. Schizophrenia in the news. Psychiatric Rehabilitation Journal 20:
51-54, 1996
31.Monahan J: 'A terror to their neighbors': beliefs about mental disorder and violence in
historical and cultural perspective. Bull Am Acad Psychiatry Law 20:191-195, 1992
32.Link BG, Cullen FT, Frank J, et al: The social rejection of ex-mental patients:
Understanding why labels matter. American Journal of Sociology 92:1461-1500, 1987
33.Monteiro VBM, Santos JQ, Martin D: Patients relatives delayed help seeking after a first
psychotic episode. Rev Bras Psiquiatr 2:104-10, 2006
34.Cirilo LS, Oliveira Filho P: Discursos de Usurios de um Centro de Ateno Psicossocial-
CAPS e de seus Familiares. Psicologia Cincia e Profisso 2:316-329, 2008
35.Wahl OF, Wood A, Richards R: Newspaper coverage of mental illness: is it changing?
Psychiatric Rehabilitation Skills 6:9-31, 2002
36.Peluso ETP, Peres CA, Blay SL: Public conceptions of schizophrenia in urban Brazil:
symptom identification and causal attribution. Soc Psychiatry Psychiatr Epidemiol
10:792-9, 2008
37.Link BG, Phelan JC, Bresnahan M, et al: Public conceptions of mental illness: labels,
causes, dangerousness and social distance. Am J Public Health 89:1328-1333, 1999
38.Gabbard GO, Gabbard K: Psychiatry and the cinema, 2nd ed. Washington, DC, American
Psychiatric Press; 1999
39.Sontag S: AIDS e suas metforas. So Paulo, Companhia das Letras, 1989
40.Rosen A, Walter G, Politis T, et al: From shunned to shining: doctors, madness and
psychiatry in Australian and New Zealand cinema. MJA 167:640-644, 1997
122
Table 1
Primary and secondary categories of articles about non-health issues, published in FSP between 2007 and
2008, that used terms related to schizophrenia.
Primary Schizophrenia/ psychosis features
Secondary category N (%)
category suggested by articles
Individuals are violent (14),
uncontrollable (4), obsessive (4), genius,
artists/ rebels (4), incapable of
discriminate real from unreal (3),
Fictional plots 37 (25.7) tormented by past (2), authoritarian and
selfish (1), mentally unbalanced (1),
strict (1), completely disabled (1). They
have double/ multiple personality (3),
delusions (2).
Individuals are aggressive (3), mentally
Literal reference unbalanced (2), incoherent (2), and
to the disorder easily influenced (1). They have double/
(69 articles) Imputed
14 (9.7) multiple personality (3), delusions (2),
schizophrenia/psychosis
unreal perceptions (2) and excessive fear
(1). Schizophrenia is an escape from
reality (1).
Individuals are authoritarian liars (4),
Pejorative label 7 (4.9) and contradictory (1). Schizophrenia is a
dissociative state (1).
Individuals are easily influenced (1),
Humoristic/ ironic
4 (2.8) aggressive (1). They have double
expression
personality (1).
Schizophrenia is similar to contradiction
(26), incoherence (8), splitting/
multiplicity (8), oscillation (4), unreality
Negative association 60 (41.6) (4), obsession (2), withdrawal (1),
indecision (1), aggression (1),
authoritarianism (1) (4 metaphors with
Metaphorical indeterminate meaning).
usage
Schizophrenia is similar to artistic
(75 articles)
features of splitting/ multiplicity (6),
Positive association 14 (9.72) peculiarity (3), aggression (1),
intermediate state (1), great creativity
(1), transformation (1), boldness (1).
Schizophrenia is similar to splitting/
Neutral association 1 (0.7)
multiplicity (1).
Note: 7 (4.86%) articles with literal reference to the disorder were classified as incidental; they are not
included in the table because these articles did not present features of the disorder .
125
Figure 2 Cartoon published in Folha de So Paulo, in July 14, 2008, an example of the
6.REFERNCIAS
Alberto RM. Perdendo a cabea: notas sobre a ira insana e a loucura furiosa no ocidente medieval
(XIII-XV). Aedos. Revista do Corpo Discente do Programa de Ps-graduao em Histria da UFRGS.
2009;2(2):362-370.
Alexander FG, Selesnick ST. Histria da psiquiatria: uma avaliao do pensamento e da prtica
psiquitrica desde os tempos primitivos at o presente. So Paulo: Ibrasa; 1968.
Alves MFP. A doena mental nem sempre doena: racionalidades leigas sobre sade e doena
mental - um estudo no Norte de Portugal. Porto. Tese [Tese de Doutoramento em Sociologia] -
Universidade Aberta; 2008.
Andreasen NC, Flaum M. Characteristic symptoms of schizophrenia. In: Widiger TA, Frances AJ,
Pincus HA, First MB, Ross R, Davis W, editors. DSM IV Sourcebook. Section III: Schizophrenia
and other psychotic disorders. 4 ed.Washington DC: American Psychiatric Press; 1994.
Andreasen NC, Nopoulos P, OLeary DS, Miller DD, Wassink T, Flaum M: Defining the phenotype
of schizophrenia: cognitive dysmetria and its neural mechanisms. Biol Psychiatry 1999 Oct; 46:908-
920.
Angermeyer MC, Matschinger H, Riedel-Heller SG. Whom to ask for help in case of a mental
disorder? Preferences of the lay public. Soc Psychiatry Psychiatr Epidemiol 1999; 34:202-210.
Angermeyer MC, Matschinger H. The stigma of mental illness: effects of labelling on public attitudes
towards people with mental disorder. Acta Psychiatr Scand. 2003;108(4):304-9.
Angermeyer MC, Matschinger H. Public beliefs about schizophrenia and depression: similarities and
differences Soc Psychiatry Psychiatr Epidemiology 2003;38:526-534.
Angermeyer MC, Holzinger A, Matschinger H. Mental health literacy and attitude towards people
with mental illness: A trend analysis based on population surveys in the eastern part of Germany.
European Psychiatry 2009;24:225-32.
127
Ajzen I, Cote NC. Attitudes and the prediction of behavior. In Crano WD, Prislin R, editors. Attitudes
and attitudes change. New York: Psychology Press; 2008.
Arbex Junior J. Showrnalismo: a notcia como espetculo. So Paulo: Casa Amarela; 2001.
Associao Nacional de Jornais. Maiores jornais do Brasil. [homepage na internet]. Os maiores jornais
do Brasil de circulao paga, por ano. [acesso 21/03/2009]. Disponvel em:
http://www.anj.org.br/a-industria-jornalistica/jornais-no-brasil/maiores-jornais-do-brasil
Bandeira M, Barroso S. Sobrecarga das famlias de pacientes psiquitricos. J Bras Psiquiatr 2005;
54(1): 34-46.
Baumann AE. Stigmatization, social distance and exclusion because of mental illness: The individual
with mental illness as a stranger. International Review of Psychiatry 2007;19:131-5.
Beer MD. Psychosis: A History of the Concept. Comprehensive Psychiatry 1996; (37)4:273-291.
Berg BL. Qualitative research methods for the social sciences. 3. ed. Boston: Allyn & Bacon; 1998.
Boke O, Aker S, Aker AA, Gokhan S, Sahin AR. Schizophrenia in Turkish newspapers: retrospective
scanning study. Social Psychiatry and Psychiatric Epidemiology 2007;42:457-61.
128
Brandli H. The image of mental illness in Switzerland. In Guimon J, Fischer W, Sartorius N, editors.
The Image of Madness: The Public Facing Mental Illness and Psychiatric Treatment. Edited by:
Basel: Karger; 1999.
Bueno WC. Jornalismo cientfico no Brasil: compromissos de uma prtica dependente. So Paulo.
Tese [doutorado] - Escola de Comunicaes e Artes da Universidade de So Paulo; 1984.
Bueno WC. Jornalismo Cientfico: Conceito e Funes. Cincia e Cultura (SBPC) 1985; 37(9):1240-
7.
Bueno WC. Jornalismo Cientfico no Brasil: aspectos tericos e prticos. So Paulo: Escola de
Comunicaes e Artes da USP; 1988.
Bueno WC. [homepage na internet]. Jornalismo cientfico. Portal do Jornalismo Cientfico, 2007.
[acesso em 31/03/2007]. Disponvel em: http://www.jornalismocientifico.com.br.
Burkett W. Jornalismo Cientfico: como escrever sobre cincia, medicina e alta tecnologia para os
meios de comunicao. Rio de Janeiro: Forense Universitria; 1990.
Byrne P. The butler(s) DID it - dissociative identity disorder in cinema. Medical Humanities 2001;
27:26-9.
Callard F, Thornicroft G, Rose D, Butler G. Shift: Mind over Matter 2: Media Survey Summary
Report. London: Institute of Psychiatry, Kings College; Apr 2008. Disponvel:
http://kc.csip.org.uk/viewdocument.php?action=viewdox&pid=0&doc=38248&grp=584
Carlsson LU: Schizophrenia throughout history. Human Brain Informatics; 2003. [acesso em
28/10/2006]. Disponvel em http://www.hubin.org/ facts/history/history_schizophrenia_en.html.
Carpenter WT, Strauss JS, Bartko J. An approach to the diagnosis and understanding of
schizophrenia: part I. Use of signs and symptoms for the identification of schizophrenic patients.
Schizophr Bull 1974;11:37-49.
Carta de Ottawa. Primeira Conferncia Internacional sobre promoo da sade. 1986 Nov 17-21;
Ottawa. [acesso em 01 Jun 2007]. Disponvel em:
http://www.opas.org.br/promocao/uploadArq/Ottawa.pdf5
129
Chess C, Salomone KL, Hance BJ. Improving risk communication in government: research priorities.
Risk Anal 1995; 15 (2): 127-35.
Chopra A, Doody GA. Schizophrenia, an illness and a metaphor: analysis of the use of the term
schizophrenia in the UK national newspapers. Journal of Royal Society of Medicine 2007;100:423-
6.
Committee for the Study of the Future of Public Health. The future of public health. Washington:
National Academy Press; 1988.
Cooper B, Kendell RE, Guraland BJ, SharpeL, Copeland JRM, Simon R. Psychiatric diagnosis in
New York and London. London: Oxford University Press; 1972.
Corin E, Lauzon G. Positive withdrawal and the quest for meaning: the reconstruction of experience
among schizophrenics. Psychiatry 1992;55:266-78.
Corrigan PW, Watson AC. Factors that explain how policy makers distribute resources to mental
health services. Psychiatric Services 2003;54:5017.
Corrigan PW, Watson AC, Gracia G, Slopen N, Rasinski K, Hall LL. Newspaper stories as measures
of structural stigma. Psychiatric Services 2005;56:551-6.
Coverdale J, Nairn R, Claasen D. Depictions of mental illness in print media: a prospective study.
Australian and New Zealand Journal of Psychiatry 2002;35:654-9.
Crawford R. You are dangerous to your health: the ideology and politics of victim blaming.
International Journal of Health Services 1977;7(4):663-680.
130
Crisp AH, Gelder MG, Rix S, Meltzer HI, Rowlands OJ. Stigmatisation of people with mental
illnesses. Br J Psychiatry. 2000;177:4-7.
Crow TJ. The Two-syndrome Concept: Origins and Current Status. Schizophrenia Bulletin 1985;
11(3) 471-488.
CSIP, Shift. Mind over matter. Improving the reporting of mental health. London: The Sainsbury
Centre for Mental Health; 2006. [acesso em 15 Jan 2007]. Disponvel em: http://www.shift.org.uk
CSIP, Shift. Mind over Matter 2. Shift Media Survey: Summary Report. London: Institute of
Psychiatry, Kings College; 2008. [acesso em 2 Set 2009]. Disponvel em:
http://kc.csip.org.uk/viewdocument.php?action=viewdox&pid=0&doc=38248&grp=584
Cuffel BJ, Shumway M, Choujian TL, MacDonald T. A longitudinal study of substance use and
community violence in schizophrenia. Journal of Nervous and Mental Disease 1994;182:704-8.
D'Amorim MA Estudo comparativo da percepo da doena mental pela comunidade. Arq Bras Psic
1981;33(1-2):75-83.
Dalgalarrondo P. Psicopatologia e semiologia dos transtornos mentais. Porto Alegre: Artmed; 2000.
Declarao de Jacarta, Indonsia. Conferncia Internacional de promoo da sade; 1992 Nov 9- 12;
Santaf de Bogot. [Acesso 01.06.2007]. Disponvel em:
http://www.opas.org.br/coletiva/uploadArq/jacarta.pdf
Dinos S. Stigma: the feelings and experiences of 46 people with mental illness. The British Journal of
Psychiatry 2004;184: 176-181.
Duckworth K, Halpern JH, Schutt, RK, Gillespie C. Use of schizophrenia as a metaphor in U.S.
newspapers. Psychiatr Serv 2003;10:1402-04.
Eagles JM, Carson DP, Begg A, Naji SA. Suicide prevention: a study of patients' views. The British
Journal of Psychiatry 2003;182:261-5.
Eagly AH, Chaiken S. The psychology of attitudes. Belmon: Wadsworth Group/Thomson Learning,
1993.
Fazel S, Gulati G, Linsell L, Geddes JR, Grann M. Schizophrenia and violence: systematic review and
meta-analysis. Plo S Med [online] 8. [acesso em Set 11 2009]. Disponvel em:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2718581/pdf/pmed.1000120.pdf
Feighner, JP, Robins, E, Guze, SB, y Cols. Diagnostic criteria for use in psychiatric research.
Archives of General Psychiatry 1972; 26:57-63.
Fernandes PT, Li LM. Percepo de estigma na epilepsia. J. Epilepsy Clin. Neurophysiol 2006;12(4):
207-218.
Fishbein MA. Consideration of beliefs, and their role in attitude measurement. In Fishbein MA, editor.
Readings in attitude theory and measurement. New York: John Wiley & Sons; 1967.
Fishbein M, Ajzen I. Belief, Attitude, Intention, and Behavior: An Introduction to Theory and
Research. Boston: Addison-Wesley Pub. Co.;1975.
Folha Online. [homepage na internet]. Tudo sobre a Folha. [acesso em 15 Jan 2009]. Disponvel em:
http://www1.folha.uol.com.br/folha/80anos/
Freimuth V. Communicating the threat of Emerging Infections to the Public. Emerging Infectious
Disease 2000; 6(4).
Gadelha AMJ, Valente JG, Schramm JMA, Portela MC, Campos MR. Projeto carga de doena. Rio de
Janeiro: ENSP/Fiocruz/FENSPTEC; 2002.
Garcia O. Comunicao em prosa moderna. Aprenda a escrever, aprendendo a pensar. Rio de Janeiro:
FGV; 1986.
Gattaz WF. Violncia e doena mental: fato ou fico? Rev Bras Psiquiatr [peridicos na Internet].
1999 Dez [acesso em 27 mar 2008]; 21(4) Disponvel em:
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-44461999000400005&lng=en
Gilman SL. Disease and Representation: Images of Illness from Madness to AIDS. Ithaca: Cornell
University Press, 1988.
Goffman E. Estigma: notas sobre a manipulao da identidade deteriorada. Rio de Janeiro: Zahar
Editores; 1975.
Groth O. Tarefas da pesquisa da cincia da cultura [1961]. In: Berger C, Marocco B, orgs. A Era
Glacial do Jornalismo: Teorias sociais da imprensa. Porto Alegre: Editora Sulina; 2007.
Hall P, Brockington IF, Levings J, Murphy C. A comparison of responses to the mentally ill in two
communities. Br J Psychiat 1993;162:99-108.
Hallam A. Media influences on mental health policy: long term effects of the Clunis and Silcock
cases. International Review of Psychiatry 2002; 14: 26-33.
Hare E. Schizophrenia as a recent disease. The British Journal of Psychiatry. 1988;153: 521-531.
133
Hastings G, Haywood A. Social marketing and communication in health promotion. Health Promotion
International 1991; 6(2): 135-145.
Hegner RE. Dispelling the myths and stigma of mental illness: the Surgeon Generals Report on
mental health. Issue Brief Natl Health Policy Forum 2000;(754):1-7.
Hernando MC. Divulgao cientfica: um grande desafio para este sculo. Cienc. Cult. [peridicos na
Internet]. 2005 Abr/Jun [acesso em 18 jul 2007]; 57(2):18-20.
Disponvel em: http://cienciaecultura.bvs.br/scielo.php?script=sci_arttext&pid=S0009-
67252005000200013&lng=en&nrm=iso
Hillert A, Sandmann J, Ehmig SC, Weisbecker H, Kepplinger HM, Benkert O: The general public's
cognitive and emotional perception of mental illness: an alternative to attitude-research. In Guimon J,
Fischer W, Sartorius N, editors. The Image of Madness: The Public Facing Mental Illness and
Psychiatric Treatment. Basel: Karger; 1999.
Hodgins S, Mednick SA, Brennan PA, Schulsinger F, Engberg M. Mental disorder and crime.
Evidence from a Danish birth cohort. Archives of General Psychiatry 1996;53:489-96.
Hollingshead A, Redlich F. Social Class and Mental Illness. New York, NY: John Wiley & Sons nc;
1958.
Huang B, Priebe S. Media coverage of mental health care in the UK, USA and Australia. Psychiatric
Bulletin 2003;27:331-3.
Hyler SE. DSM-III at the cinema: madness in the movies. Comprehensive Psychiatry 1998;29:195-
206.
Jones E, Farina A, Hastof A, Markus H, Miller DT, Scott RA. Social Stigma: the psychology of
marked relationships. New York: Freeman and Company; 1984.
Jones NF, Kahn MW, MacDonald JM. Psychiatric patients views of mental illness, hospitalization and
treatment. Journal of Nervous and Mental Disease 1963; 36(1):82-7.
Jones S, Hayward P. Coping with Schizophrenia: A Guide for Patients, Families and Carers. Oxford:
Oneworld Publications; 2004.
134
Jorm AF, Griffiths KM. The publics stigmatizing attitudes towards people with mental disorders:
how important are biomedical conceptualizations? Acta Psychiatr Scand 2008;118: 315321.
Josef F, Silva JAR. Doena mental e comportamento violento: novas evidncias da pesquisa. Jornal
Brasileiro de Psiquiatria. 2003;52:127-35.
Junqueira L. Gesto intersetorial das polticas sociais e o terceiro setor. Sade e Sociedade
2004;13:25-36.
Kaplan Hi, Sadock Bj. Compndio de Psiquiatria. Porto Alegre: Artemed, 1999.
Kitzinger J. A sociology of media power: key issues in audience reception research. In: Philo G,
editor. Message Received. Essex: Addison Wesley Longman; 1999.
Klin A, Lemish D. Mental disorders stigma in the media: review of studies on production, content,
and influences. J Health Commun 2008; 13(5):434-49.
Knutson JN. The human basis of the polity: A psychological study of political men. Chicago: Aldine;
1972.
Koga M; Furegato AR. Convivncia com a pessoa esquizofrnica: sobrecarga familiar. Cincia,
Cuidado e Sade 2002; 1(1): 75-79.
Kraus S.Attitudes and the Prediction of Behavior: A Meta-Analysis of the Empirical Literature. Pers
Soc Psychol Bull 1995; 21(1): 58-75.
Korn, M.L. (2001). Historical Roots of Schizophrenia. Retrieved April 15, 2006 from:
http://www.medscape.com/viewprogram/131 pnt
Kuscinsky B. Jornalismo e sade na era neoliberal. Sade Soc So Paulo 2002; 11 (1): 95-103.
Kyziridis TC. Notes on the History of Schizophrenia. The German Journal of Psychiatry 2005; 8(3),
42-48.
135
Labonte R. Health promotion and empowerment: practice frameworks. Toronto: Centre for Health
Promotion; 1993.
Labonte R. Community development in the public health sector: the possibilities of an empowering
relationship between state and civil society. Toronto. Dissertao [Dissertao de Ps-doutorado] -
York University; 1996.
Lalonde M. A new perspective on the health of Canadians. Ottawa: Health and Welfare; 1974.
Lane RE. Political ideology: Why the American common man believes what he does. New York: Free
Press; 1962.
Larsson A, Oxman A, Carling C, Herring J. Medical messages in the media-barriers and solutions to
improving medical journalism. Health Expect 2003; 6(4):323-31.
Lauber C, Nordt C, Falcato L, Rssler W. Lay recommendations on how to treat mental disorders. Soc
Psychiatry Psychiatr Epidemiol 2001; 36:553-556.
Lauber C, Nordt C, Falcato L, Rssler W Do people recognise mental illness? Factors influencing
mental health literacy. Eur Arch Psychiatry Clin Neurosci 2003; 253:248251.
Laugksch RC. Scientific literacy: a conceptual overview. Science Education 2000; 84(1):71-94.
Lawrie SM. Newspaper coverage of psychiatric and physical illness. The Psychiatrist 2000;24:104-6.
Leff J, Warner R. Incluso social de pessoas com doenas mentais. Coimbra: Almedina; 2006.
Liddle TJ. The Two-syndrome Concept: Origins and Current Status. The British Journal of Psychiatry
1987;151: 145-151.
Link BG, Cullen FT, Frank J, Wozniak JF. The social rejection of former mental patients:
understanding why labels matter. American Journal of Sociology 1987;92:1461-1500.
Link BG, Phelan JC, Bresnahan M, Stueve A, Pescosolido BA. Public conceptions of mental illness:
labels, causes, dangerousness and social distance. Am J Public Health 1999; 89:1328-1333.
Link BG, Phelan JC. Conceptualizing Stigma. Annu Rev Sociol 2001; 27:363-85.
136
Lopes JL. A psiquiatria na poca de Freud. evoluo do conceito de psicose em psiquiatria. Rev Bras
Psiquiatr 2001;23(1):28-33.
Maranini N, Camargo S, Paz D, Fonseca WC, Bueno WC. [homepage na internet]. Divulgao de
sade na imprensa brasileira: expectativas e aes concretas, 2007. [acesso em 31 Mar 2007].
Disponvel em:
http://www.comunicasaude.com.br/comunicasaude/artigos/jornalismo_saude/artigo10.php
Marcondes Filho, Ciro. O capital da notcia: jornalismo como produo social da segunda natureza.
So Paulo: tica; 1989.
Mari JJ, Streiner D. An overview of family interventions and relapse on schizophrenia: meta-analysis
of research findings. Psychological Medicine 1994;24:565-78.
Mason T. Tarasoff liability: its impact for working with patients who threaten others. International
Journal of Nursing Studies 1998;35:109-14.
Matas M, El-Guebaly N, Harper D, Green M, Peterkin A. Mental illness and the media, Part II:
Content analysis of press coverage of menal health topics. Canadian Journal of Psychiatry
1986;30:431-133.
Matschinger H, Angermeyer MC. The publics preferences concerning the allocation of financial
resources to health care: Results from a representative population survey in Germany. European
psychiatry: The journal of the Association of European Psychiatrists 2004;19:478-82.
McCombs ME, Shaw DL. The agendasetting function of mass media. Public Opinion Quarterly
1972;36(2):176-187.
McNally K. Schizophrenia as split personality/Jekyll and Hyde: the origins of the informal usage in
the English language. Journal of the History of the Behavioral Sciences 2007;1:69-79.
Medeiros RP. Cincia e imprensa: a fuso a frio em jornais brasileiros. Dissertao [Dissertao de
mestrado] - Escola de Comunicao e Artes da Universidade de So Paulo; 1996.
137
Mendes DD, Mari JJ, Singer M, Barros GM, Mello AF. Estudo de reviso dos fatores biolgicos,
sociais e ambientais associados com o comportamento agressivo. Revista Brasileira de Psiquiatria
2009;31(Suppl. 2):77-85.
Miles A. A famlia do doente mental. In: Miles A, editor. O doente mental na sociedade
contempornea. Rio de Janeiro: Zahar; 1982.
Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em sade. 7. ed. So Paulo: Hucitec,
2000.
Monahan J. A terror to their neighbors: beliefs about mental disorder and violence in historical and
cultural perspective. Bulletin of the American Academy of Psychiatry & the Law 1992;20:191-5.
Monteiro VBM, Santos JQ, Martin D. Patients relatives delayed help seeking after a first psychotic
episode. Revista Brasileira de Psiquiatria 2006;28:104-10.
Mora AMS. A divulgao da cincia como literatura. Rio de Janeiro: Casa da Cincia; 2003.
Mulvey EP. Assessing the evidence of a link between mental illness and violence. Hospital and
Community Psychiatry 1994;45:663-8.
Murray CJL, Lopez AD. The Global Burden of Disease. Geneva: World Health Organization, Harvard
School of Public Health, World Bank, 1996.
Nairn R, Coverdale J, Claasen D. From source material to news story in New Zealand print media: a
prospective study of the stigmatizing processes in depicting mental illness. Australian and New
Zealand Journal of Psychiatry 2001;35:654-9.
National Union of Journalists. The reporting of mental health and suicide by the media. A practical
guide for journalists. [monografia na Internet]. Scotland: National Union of Journalists; 2004. [acesso
em 22 Jun 2007]. Disponvel em: http://iasp.info/pdf/task_forces/Scotland_Reporting_Media.pdf
Nelkin D. Selling Science - How the press covers science and technology. Nova York: W.H. Freeman
and Company; 1995.
Neuman WL. Social research methods. 2. ed. Boston: Allyn & Bacon; 1994.
138
Okasha A. Mental Health in Egypt. Isr J Psychiatry Relat Sci 2005;42 (2):116125.
Orlandi EP. Discurso e texto: formao e circulao dos sentidos. Campinas: Pontes; 2001.
stman M, Kjellin L. Stigma by association. Psychological factors in relatives of people with mental
illness. British Journal of Psychiatry 2002;181, 494-498.
Pelbart PP. Da clausura do fora ao fora da clausura: loucura e desrazo. So Paulo: Editora
Brasiliense; 1989.
Peluso ETP. A percepo pblica de transtornos mentais na cidade de So Paulo. Tese [Tese de
Doutoramento em Cincias da Sade] - Departamento de Psiquiatria e Psicologia Mdica da
Universidade de So Paulo; 2004.
Peluso ETP, Peres CA, Blay SL. Public conceptions of schizophrenia in urban Brazil. Social
Psychiatry and Psychiatric Epidemiology 2008 43:792-9.
Peluso ETP, Blay SL. Public beliefs about the treatment of schizophrenia and depression in Brazil.
International Journal of Social Psychiatry 2009; 5:16-27.
Peluso ETP, Blay SL. (in press). Public stigma and schizophrenia in So Paulo city. Revista Brasileira
de Psiquiatria [online]. [acesso em 23Maio 2010]. Disponvel em:
http://www.scielo.br/pdf/rbp/2010nahead/aop0410.pdf
Penn DL, Kohlmaier JR, Corriganc PW. Interpersonal factors contributing to the stigma of
schizophrenia: social skills, perceived attractiveness, and symptoms. Schizophrenia Research
2000;45:37-45.
Pereira MAO. Representao da doena mental pela famlia do paciente. Interface (Botucatu).
2003;7(12): 71-82.
139
Perlick DA, Rosenheck RA, Clarkin JF, Sirey JA, Salahi J, Struening EL, Link BG. Stigma as a
barrier to recovery: adverse effects of perceived stigma on social adaptation of persons diagnosed with
bipolar affective disorder. Psychiatric Services 2001;52:1627-1632.
Pharoah F, Mari JJ, Rathbone J, Wong W. Family intervention for schizophrenia. Cochrane Database
of Systematic Reviews. 4, Art. N: CD000088. 2006.
Philo G. Media representations of mental health/illness: audience reception study. Glasgow: Glasgow
University Media Group; 1994.
Philo G, McLaughlin G, Henderson L. Media content. In Philo G, editor. Media and Mental Distress.
Essex: Addison Wesley Longman; 1996.
Pope H, Lipinski J. Diagnosis of schizophrenia and manic-depressive illness. Arch Gen Psychiatry
1978;35:811-28.
Porter R. Uma Histria Social da Loucura. Rio de Janeiro: Jorge Zahar Editor; 1990.
Porter R. Can the stigma os mental illness be changed? The Lancet 1998; 352(26): 1049-1059.
Prewitt K. "Scientific illiteracy and democratic theory". Daedalus 1983; 112; 49-64
Rabkin JG. Opinions about mental illness: a review of the literature. Psychol Bull 1972; 77(3): 153-
171.
Raichvarg D, Jacques J. Savants et ignorants - une histoire de la vulgarization des sciences. Paris:
ditions du Seil; 1991.
Rangel ML. Comunicao no controle de risco sade e segurana na sociedade contempornea: uma
abordagem interdisciplinar. Cinc Sade Coletiva 2007; 12 (5):1375-1385.
Read J, Haslam N, Sayce L, Davies E. Prejudice and schizophrenia: a review of the mental illness is
an illness like any other approach. Acta Psychiatr Scand 2006; 114:303-318.
Read J. Why promoting biological ideology increases prejudice against people labeled
schizophrenic. Aust Psychol 2007;42:118128.
Reis JC. O Sorriso de Hipcrates: A Integrao Biopsicossocial dos Processos de Sade e Doena.
Lisboa: Vega; 1998.
Reis J. Ponto de vista: Jos Reis [entrevista]. In: Massarani L, Moreira IC, Brito F, orgs. Cincia e
Pblico: caminhos da divulgao cientfica no Brasil. Rio de Janeiro: Casa da Cincia; 2002.
Renshon J. Stability and Change in Belief Systems. The Operational Code of George W. Bush.
Journal of Conflict Resolution 2008; (52) 6:820-849.
Robertson A. Shifting discourses on health in Canada: from health promotion to population health.
Health Promotion Internat 1998; 13(2): 156-66.
Rogers EM, Story JD. Communication campaigns. In: Berger C, Chaffe S, editors. Handbook of
communication science. Newburg Park: Sage Publication; 1987.
Rsch N, Angermeyer MC, Corrigan PW. Mental illness stigma: Concepts, consequences, and
initiatives to reduce stigma. European Psychiatry 2005; 20:529539.
Sartorius N. Early manifestation and first contact incidence of schizophrenia in different cultures.
Psychological Medicine 1986;16:909-28.
Saunders, J. C. Families living with severe mental illness: a literature review. Issues in Mental Health
Nursing 2003; 24 (2):175-198.
Schizophrenia Ireland, Lucia Foundation. Guide for Journalists and Broadcasters. Reporting on
Schizophrenia. [monografia na Internet]. Ireland:Lucia Foundation; 1999. [acesso em 22 Jun 2007].
Disponvel em: http://www.sirl.ie/other/repository_docs/82.pdf
141
Schulze B, Angermeyer M.C. Subjective experiences of stigma. A focus group study of schizophrenic
patients, their relatives and mental health professionals. Social Science & Medicine 2003; 56:299-312.
SES. (Secretaria de Estado de Sade do Estado de So Paulo). Cartilha dos Direitos do Paciente do
SUS. [cartilha na internet]. So Paulo: Secretaria de Estado de Sade do Estado de So Paulo; 1999.
[acesso em 23 Ago 2008]. Disponvel em: http://www.saude.sp.gov.br.guiacidadao
Shain RE, Phillips J. The stigma of mental illness: labeling and stereotyping in the news. In: Wilkins
L, Patterson P, editors. Risky Business: Communicating Issues of Science Risk and Public Policy.
Westport:Greenwood; 1991.
Sharpey C F. Public perceptions of four mental health professions: a survey of knowledge and
attitudes to Australian Psychologist 1986;21: 57-67.
Shirakawa I. Ajustamento Social Na Esquizofrenia. 4 ed. So Paulo: Casa Leitura Mdica; 2009.
Simpson CJ. The stigmata: pathology or miracle? Br Med J (Clin Res Ed)1984; 289:1746-8.
Social Exclusion Unit. Mental Health and Social Exclusion. London: Office of the Deputy Prime
Minister; 2004.
Sosowsky L. Explaining the increased arrest rate among mental patients: A cautionary note. The
American Journal of Psychiatry 1980;137:1602-5.
Spitzer RL, Endicott J, Robins E. Research Diagnostic Criteria. Arch Gen Psychiatry 1978;35(6):773-
782.
Stark C, Paterson B, Devlin B. Newspaper coverage of a violent assault by a mentally ill person.
Journal of Psychiatric and Mental Health Nursing 2004;11:635-43.
142
Strauss JS, Carpenter WT. Prediction of outcome in schizophrenia. III. Five-year outcome and its
predictors. Arch Gen Psychiatry 1977;34(2):159-63.
Stuart H, Arboleda-Flrez J. Community attitudes toward people with schizophrenia. Can J Psychiatry
2001; 46:245-252.
Swanson J, Estroff S, Swartz M, Borum R, Lachicotte W, Zimmer C, et al. Violence and severe
mental disorder in clinical and community populations: the effects of psychotic symptoms,
comorbidity, and lack of treatment. Psychiatry 1997;60:1-22.
Teixeira M. Pressupostos do jornalismo de cincia tal como praticado no Brasil e suas repercusses
no modo da cobertura. Parcerias Estratgicas 2001;13: 323-329.
Terris M. Concepts of health promotion: dualities in public health theory. J Public Health Policy 1992;
13:267-76.
Tessler RC, Gamache GM. Family Experiences with Mental Illness. Westport: Auburn House; 2000.
Thompson AH, Stuart H, Bland RC, Arboleda-Florez J, Warner R, Dickson RA. Attitudes about
schizophrenia from the pilot site of the WPA worldwide campaign against the stigma of
schizophrenia. Soc Psychiatry Psychiatr Epidemiol 2002; 37:475-482.
Thornicroft G. Shunned. Discrimination against people with mental illness. Oxford: Oxford
University Press; 2006.
Thornicroft G, Alem A, Santos RAD, Barley E, Drake RE, Gregorio G, et al. WPA guidance on steps,
obstacles and mistakes to avoid in the implementation of community mental health care. World
Psychiatry 2010;9:67-77.
Tiihonen J, Isohanni M, Rasanen P, Koiranen M, Moring J. Specific major mental disorders and
criminality: a 26-year prospective study of the 1966 northern Finland birth cohort. American Journal
of Psychiatry 1997;154:840-45.
Tsu TMJA, Tofolo V. Concepes etiolgicas de pacientes psiquitricos sobre doena mental. Psicol.
USP 1990; 1(2):155-60.
143
U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving
Health. 2 ed. Washington, DC: U.S. Government Printing Office, November 2000.
Vergara MR. Reflexes acerca da educao em peridicos cientfico literrios do sculo XIX no Rio
de Janeiro: os ideais da gerao de 1870. Revista gora 2008; 8:1-13.
Villares CC, Redko CP, Mari JJ. Concepes de doena por familiares de pacientes com diagnstico
de esquizofrenia. Rev Bras Psiquiatr 1999; 21(1): 36-47.
Wahl OF. Mass media images of mental illness: a review of the literature. Journal of Community
Psychology. 1992;20:343-52.
Wahl OF. Brief reports. Schizophrenia in the news. Psychiatric Rehabilitation Journal 1996;20:51-4.
Wahl OF. Mental Health Consumers Experience of Stigma. Schizophrenia Bulletin 1999; 25(3): 467-
478.
Wahl OF, Wood A, Richards R. Newspaper coverage of mental illness: Is it changing? Psychiatric
Rehabilitation Skills 2002; 6(1):9-31.
Wahl OF. News media portrayal of mental illness. Implications for public policy. American
Behavioral Scientist 2003;46:1594-1600.
Wallace C, Mullen P, Burgess P, Palmer S, Ruschena D, Browne C. Serious criminal offending and
mental disorder. Case linkage study. British Journal of Psychiatry. 1998;172:477-84.
Walsh E, Buchanan A, Fahy T. Violence and schizophrenia: examining the evidence. British Journal
of Psychiatry. 2002;180:490-5.
Walter G. The stereotype of the mad psychiatrist Australian and New Zealand Journal of Psychiatry
1989; 23: 547-554
Ward G. Making headlines. Mental health and the national press. London: Health Education
Authority, 1997.
Weinstein RM, Brill NQ. Conceptions of mental illness by patients and normals. Mental Hygiene
1971; 55(1):101-7.
144
World Health Organization. Health Promotion Glossary. Geneva: World Health Organization 1998.
WHO/HPR/HEP/98.1
7.APNDICE
1. Dubugras MTB, Mari JJ, Santos JFFQ. A imagem do psiquiatra em filmes ganhadores do Prmio
da Academia entre 1991 e 2001. Revista de Psiquiatria do Rio Grande do Sul, v.29, p.100-109,
2007. Disponvel em: http://www.scielo.br/pdf/rprs/v29n1/v29n1a18.pdf
2. Razzouk D, Zorzetto R, Dubugras MTB, Gerolin J, Mari JJ. Leading countries in mental health
research in Latin America and the Caribbean. Revista Brasileira de Psiquiatria, v.29, p.118 - 122,
2007. Disponvel em: http://www.scielo.br/pdf/rbp/v29n2/a06v29n2.pdf
3. Razzouk D, Zorzetto R, Dubugras MTB, Gerolin J, Mari JJ. Mental health and psychiatry research
in Brazil: scientific production from 1999 to 2003. Revista de Sade Pblica, v.40, p.93 - 100,
2006. Disponvel em: http://www.scielo.br/pdf/rsp/v40nspe/30628.pdf
4. Zorzetto R, Razzouk D, Dubugras MTB, Gerolin J, Schor N, Guimares J., Mari JJ. The scientific
production in health and biological sciences of the top 20 Brazilian universities. Brazilian Journal
of Medical and Biological Research, v.39, p.1513-1520, 2006.
Docente em cursos
Palestras ministradas
Apresentao de trabalho
Dubugras MTB, Mari JJ. A Two-Year Cross-sectional Study on the Information Disseminated about
Schizophrenia in a Prestigious Daily Brazilian Newspaper. (Pster) XVII Congresso Brasileiro de
Psiquiatria, 2009.
Dubugras MTB, Mari JJ. A Two-Year Cross-sectional Study on the Information Disseminated about
Schizophrenia in a Prestigious Daily Brazilian Newspaper. In: XXVII Congresso Brasileiro de
Psiquiatria, 2009, So Paulo. Anais do XXVII Congresso Brasileiro de Psiquiatria, 2009. v. CD-ROM.