By Živa Verdnik

How do you know if you are mad? Maybe you are the only sane one in the world of madness. And yet, that makes you mad again, does it not? And while thinking about it, ask yourself a question:

“What is madness? “ First idea that came into my mind was a picture of a mentally ill person. And that is completely expected – we believed for a very long time that being mentally ill meant that you were crazy. Why?

I am going to try to answer that question by discovering the closest thing to madness I could think of – the schizophrenia.

Schizophrenia is a disease that was practically unknown until the early 20th century and as such usually mistaken as madness. Reports of irrational, peculiar and uncontrolled behaviour rarely appear before the 19th century. That of course does not mean that people did not notice the impact of the illness on the potential patients – different kinds of mental sicknesses were recognised already in Ancient Egypt, Greece and Rome, but they were never scientifically observed, categorised or medically treated. First mental illness description that had similar symptoms as schizophrenia was written in Arabic medical and psychological literature in the middle ages. It was categorised as a variation of madness, such as rabies, mania and manic depression (today known as bipolar disorder) and stayed as such until the 19th century. Schizophrenic patients throughout the history were usually represented as mystics, saints, or victims of evil spirits or a devil that possessed them. Those patients were treated (usually by priests) with different methods of exorcism – for example listening to special kind of music as very harmless method and even extreme and painful techniques such as drilling holes into a patient’s head to let the bad spirits escape.

In the late 19th century scientist began to study mental diseases more actively and soon made progress on schizophrenic researches, too. In 1886 Heinrich Schüle used a term dementia praecox to describe the disease and with that categorised it as a kind of dementia (wide spectre of diseases that make the patient lose ability to think and remember).

The term was also used by Emil Kraepelin, who separated schizophrenia from other similar mental diseases and significantly impacted on development in schizophrenic field. In 1909 Euhen Bleuler discovered that schizophrenia is not a dementia and renamed it as “schizophrenia”, which translates to Greek as “splitting of the mind”. The name represents the separation of function between personality, thinking, memory, and perception of the schizophrenic patient and is (because of its name) today commonly mistaken as bipolar disorder. In the early 20th century Kurt Schneider made a list of symptoms that distinguish schizophrenia from other diseases.

Many schizophrenic patients in the 20th century became victims of eugenics, the movement which wanted to improve genetic quality of human population by reducing the reproduction of people with bad genes (as such were also categorised people with mental sickness) by sterilizing them with or without their consent.

The movement appeared mostly in the USA, Scandinavian countries and in Nazi Germany, where many people diagnosed with mental illness were killed in Nazi Action-T4 program. That began with eugenics movement, encouraged by German scientists Ernest Rüdin and Freanz Kallmann – they believed that schizophrenia is transmitted by regressive gene, and can be therefore destroyed if mentally ill people are prevented to reproduce. That supported the idea of “sterilization” law, which was legalised in 1933. A couple of years later Hitler agreed with the law and ordered the killing of patients with carbon monoxide. The rest of them starved – those who were able to work got minimal level of calories to survive and the rest of them were on vegetable-only diet. To that American hospitals reacted with: “Germans are beating us at our own game.”

But throughout history movements that fought and supported schizophrenic patients appeared, too. Anti-psychiatrists, for example, thought that schizophrenic patients (as well as other mentally ill people) appear crazy because they are very intelligent and too sensitive to live in such a harsh world.

In the 70’s there was another turning point. It was proposed that where patients completely recovered it was not really a case of schizophrenia and new diagnostic criteria for the disease were established, which are the base for diagnostic of schizophrenia even today.

But the criteria were not globally the same. In America, for example, the criteria were not as strict as in Europe and because of that there were more patients diagnosed in the USA. The criteria can also be abused – in Russia Andrei Snezhnevsky used fake criteria to help imprison political opponents faster and easier. That was taking action until west interfered. Today the criteria is still under change – that is how patients can be offered the best help and be diagnosed quickly and effectively.

But to be able to recognise the disease, you must be well educated about it. Nowadays we are definitely more familiar with the disease itself than we were ever before, but we still don’t exactly know why it appears. We know that is a disease of a frontal cortex, where problems with basic cognitive functions (functions that control interference with the outside world) and working memory appear. That is the memory that keeps information for some time, and if that information is important to us it will store up in the long-lasting memory. If we do not find it important we will soon forget it. Problems in most cases appear when level of dopamine in the brain is too high. Dopamine is the so called “happy hormone” that helps transport information between neurons. It makes us more creative, encourages our imagination and makes us feel happy. For instance, when we eat a piece of chocolate it raises dopamine levels in our brain and makes us feel happy. We also have dopamine-mediated reward system in our brain that causes wanting for substances that caused higher level of dopamine. In simple words, it can cause an addiction. That is more noticeable in heavier drugs, like crystal meth, heroin, cocaine and nicotine. But higher levels of dopamine and problems that come with it usually appear in the early twenties for men and late twenties for women. That is because frontal cortex is one of the most complex parts of our brain and is not fully evolved before.

Today we think that schizophrenia is caused by different genetic factors, combined with environment stressors (everyday situations that are stressful for us). For example, if one of the parents has schizophrenia it is more likely that children will have it, too (on the table below possible risks according to shared genes with schizophrenic patient are listed). But genes are not the only ones that have influence on the potential disease development. In identical twins, who share 100% of genetic code, the disease risk only takes up to 48%, which means there must be other non-genetic influences that can cause schizophrenia.

One of them might be prenatal factors – those are factors that influence mother while being pregnant and consequently impact child’s health. Prenatal factors such as bad food habits, virus exposure, incompatible Rh factor, depression or even low social status, that can be a stressor for the mother, can cause premature and difficult birth, low birth weight and later problems in child’s development, one of which can also be different mental illnesses.

But scientists still cannot confirm that these factors cause schizophrenia. Only thing discovered about environment influence is social and emotional state of the patient when already diagnosed. So, different stressful situations can worsen the symptoms and maybe even cause the disease. If, for instance, patient’s home environment does not make him feel secure, supported and loved, that can make potential disease outbreaks more possible. Amphetamine, cocaine and rarely alcohol can also cause similar symptoms to schizophrenia, but it has not been proven that they cause the disease itself. Schizophrenic patients statistically also smoke more marihuana and are regular cigarette smokers more often. But even though marihuana does not have any effect on disease development, it can make its symptoms worse.


General population ? 1%
Cousin 12.5% 2%
Uncle/Aunt 25% 2%
Niece/Nephew 25% 4%
Granddaughter/Grandson 25% 5%
Half-brother/sister 25% 6%
Parent 50% 6%
Sibling 50% 9%
Child 50% 13%
Fraternal twin 50% 17%
Identical twin 100% 48%


Symptoms of schizophrenia contain positive and negative symptoms – positive meaning the symptoms that give the patient new sensation, like hallucinations, delusions, disorganised behaviour, speaking and thinking, and catatonic behaviour (weird body reactions on the environment, such as weird body positions, unresponsiveness and pointless movement). The negative symptoms are the loss of some functions or capabilities, like an ability to speak fluently, and think coherently. Patients also seem more emotionless and not interested in the world around them. Those two types of symptoms are exchanging in an outbreak of the disease, which has three stages – the preparation stage, where a person feels anxious, depressed and uncomfortable. Then comes the second or so called active phase, in which a patient has positive symptoms and lastly the final stage, where a person has negative symptoms. The whole outbreak is about 6 months long and while lasting the patient usually also has sleeping, and food disturbances, problems with memory and concentration and feels irritated or depressed.

Because of its complexity and symptoms, similar to other mental illnesses, schizophrenia can often be diagnosed wrong. To make diagnosis simpler doctors today use special diagnostic criteria. The disease has to last for 6 months (the active stage 1 month) and has to affect personal life of the patient. Before the diagnosis a doctor should eliminate possibility of schizoaffective disorder or mood disorders and check if the disorder doesn’t appear because of drugs, general health problems or any other development disorders. But the diagnosis can still be wrong because of different cultural background. For instance, a completely normal behaviour in the East could be seen as weird in the West. Cultural differences are also the reason why in the USA more black people are being diagnosed with schizophrenia.


The disease is being cured with combination of drugs and psychotherapy. We usually cure schizophrenia with antipsychotics that have positive effects on 70% of patients and begin to work after 5 to 10 weeks. In the past they had a lot of unwanted side effects that mostly do not appear in today’s drugs. According to statistic schizophrenic patients have higher chance of getting sick with other diseases too, such as diabetes, higher blood pressure etc. and have shorter life spam, which is mostly because of high suicide rate. Ten percent of patients usually do not (socially and mentally) recover from the outburst of the disease, but most of them begin to live normally again.


Schizophrenia has also had an effect on the culture, appearing in literature, music, movies and in the pop culture. The sixties, for instance, were the golden age of newly discovered drugs like LSD. They caused symptoms similar to hallucinations, which was the source of inspiration for many musicians and artists. That is when psychedelic rock appeared and was even later played by many famous bands like The Beatles, The Doors, Pink Floyd, The Rolling Stones, The Animals, The Who and musicians like Jimmy Hendrix, Janis Joplin and many others. But “psychedelic vibe” was not only found in music – it was an important part of a hippie culture that appeared at that time. But psychedelic themes also appear a lot earlier, in literature. One of the most famous representations of schizophrenia on that area is definitely Alice’s Adventures in Wonderland by Lewis Carroll, later made in to a bunch of movies. In them Alice was supposedly schizophrenic and whole Wonderland just a product of her hallucinations. The use of nonsense and questions that the author asks the reader surely bring the whole concept of being “mad” in a completely new light. It makes the reader doubt who really is the mad one here: he himself or the book characters. But a beautiful and usually very true meaning is hidden in the nonsense in Carroll’s quotes:


“I am not crazy, my reality is just different than yours.”


“If you do not know where you’re going, any road will get you there.”


“How do you know I’m mad?” said Alice. “You must be,” said the cat, “Or you wouldn’t have come here.”


“Would you tell me, please, which way I ought to go from here?”

“That depends a good deal on where you want to get to.”

“I don’t much care where –”

“Then it doesn’t matter which way you go.”


“Who in the world am I? Ah, that’s the great puzzle.”


“Why, sometimes I’ve believed as many as six impossible things before breakfast.”


“I don’t think …”

“Then you shouldn’t talk,”


“How long is forever?”

“Sometimes, just one second.”


The Mad Hatter: “Have I gone mad?”

Alice: “I am afraid so. You are entirely bonkers. But I’ll tell you a secret. All the best people are.”


So if you still wonder about madness … you are quite helpless. Because, no matter how we try to understand it – through books, music, science or your personal ideas -in the end there is just you and your mind. So if you ever wonder about your sanity again, you just need to remember … “We are all mad here.”




Tomaž Erzar – Duševne motnje