Psychiatry, as a medical discipline, is closely tied to historical and societal developments. Cultural beliefs, norms and values shape how mental disorders are perceived and defined, leading to diverse representations across cultures. Reference Berrios and Porter1
Cultural products – music, film and literature – both reflect and shape public understandings of mental illness. Media exposure shapes attitudes and behaviours; in the absence of direct contact with individuals with mental disorders, perceptions are guided by these culturally mediated representations. Reference Gerbner and Thayer2,Reference Bandura3
Social representations constitute socially constructed knowledge shaping collective understanding. Stuart Hall posits that representations connect meaning with language, thereby linking language to culture. Reference Hall4 Analysing mass media and popular culture is essential for understanding prevailing ideas about mental disorders and their societal impact. For analytical purposes, this study embraces culture as ‘the works and practices of intellectual and artistic activity’ and ‘mediated popular culture’. Reference Sellnow5 Consequently, popular artistic manifestations are considered valuable sources for accessing representations of psychotic disorders within a specific population.
Historically, media analyses indicate that portrayals of individuals with mental disorders – especially psychotic disorders – frequently emphasise violence, criminality, unpredictability and social incompetence. Reference Camp, Webster, Coverdale, Coverdale and Nairn6–Reference Wahl and Kaye8 These depictions reinforce stigma and hinder acceptance of diagnoses. Stigma and discrimination remain significant barriers to mental health awareness and access to psychiatric care. Reference Satcher9
The current study
Despite the well-documented influence of media on perceptions of mental illness, Reference Granello and Pauley10,Reference Reda11 research on artistic expressions – particularly music – remains scarce. Reference Pavez, Saura, Pérez and Marset12 Our previous article in this journal Reference Pavez, Saura and Marset13 explored portrayals of the psychiatrist and psychiatric treatments in Spanish punk music. The current study continues this exploration, examining representations of psychotic disorders in the same corpus of songs. We hypothesise that these representations are diverse and sometimes confusing.
The aim of this study is threefold: (a) to explore how psychotic disorders are represented in Spanish punk music between 1981 and 2010; (b) to assess whether these representations mirror, distort or challenge broader cultural attitudes toward psychosis and other mental illness; and (c) to offer a replicable framework for analysing mental illness representations in other musical genres or cultural media through a combined qualitative–quantitative approach.
Method
A mixed qualitative–quantitative approach was employed to analyse Spanish punk lyrics from 1981 to 2010, identifying patterns, themes and relationships within the content.
Punk music offers a valuable model for studying subcultural depictions of mental illness. It provides: (a) a historical trajectory parallel to the Psychiatric Reform and the rise of community mental health in Spain; (b) explicit lyrics reflecting everyday language, facilitating coder agreement; (c) potential representation of marginalised groups, including those with mental illness, as previous reports suggest; Reference Pavez14,Reference McDonald15 and (d) a demographic connection, as punk is associated with youth – a period of increased vulnerability to substance use and psychotic symptoms. Reference Kirkbride, Hameed, Ankireddypalli, Ioannidis, Crane and Nasir16
Content analysis identified the frequency of references and thematic groups, and thematic analysis provided interpretative depth. An inductive approach allowed themes to emerge organically. Two independent coders conducted the analysis to enhance reliability. Quantitative data were analysed using frequency measures.
Sampling
Purposeful sampling of punk bands was conducted using bibliographic, documentary and online sources (Supplementary Material 1, available online at https://doi.org/10.1192/bjb.2025.10175). Songs thematically related to psychosis were transcribed. Exclusion criteria included non-Spanish lyrics, cover songs, poetry set to music, and instrumental tracks. Duplicate songs were considered only once.
Content analysis
Coding proceeded iteratively with data collection. In vivo codes were first generated, then organised into discrete categories. An open coding system allowed new categories to be incorporated as they emerged from the text, ensuring a flexible, data-driven approach.
Transcripts were subjected to iterative review, with marginal notes, keywords and thematic labels. Significant content was coded, and data were organised into comparable units. Coding continued until data saturation was reached.
Thematic analysis
Thematic analysis followed Braun & Clarke’s six-phase structure. Reference Braun, Clarke and Cooper17
Ethics
This study used publicly available data without identifiable personal information and therefore did not require ethical approval.
Results
A total of 177 Spanish punk bands were included, with 5647 songs meeting the inclusion criteria. Content related to psychotic disorders appeared in 2.28% (n = 129) of the songs, with two identifiable subgroups. Group 1 (n = 79) consisted of songs in which psychotic disorders were the central theme, and group 2 (n = 50) included songs with references to specific psychopathological terms related to psychoses as secondary themes, such as schizophrenia/schizophrenic, psychosis, schizoid, paranoia, delirious/delusional/delusion, hallucinate/hallucination (Fig. 1).
Fig. 1 Content search process in 5647 punk songs (Spain, 1981–2010): composition of subgroups. n, number of songs.
Most references to psychotic disorders in group 1 were expressed in a general and non-specific manner (n = 37), followed by allusions to psychopathological symptoms related to psychosis (n = 14). Examples include colloquial terms such as loco, demente or locura, frequently used in lyrics or titles (26 songs). Of the total references, 10 specifically alluded to schizophrenia. Other depictions suggested delusional or paranoid reactions (n = 8) and substance-related psychoses (n = 7), linked to lysergic acid diethylamide (LSD), cocaine, alcohol, cannabis and other drugs. References to multiple symptoms or diagnoses of psychotic disorders within the same song (n = 2), as well as portrayals suggesting psychogenic psychoses (n = 1), were infrequent (Table 1).
Table 1 Examples of depictions of psychotic symptoms and disorders in Spanish punk songs
Regarding psychiatric diagnoses, the terms ‘paranoia’ and ‘schizophrenia’ were the most commonly referenced. When combining data from group 1 and group 2, 42 songs (32.56%) mentioned the terms ‘paranoia’ or ‘paranoid’, and 17 songs (13.18%) referred to ‘schizophrenia’ or ‘schizophrenic’. ‘Paranoia’ was used mainly as a generic disturbance (41.6%), although at times as a personality trait or a reaction to social circumstances or surveillance systems (20.93%) or as a psychotic symptom (18.6%). In other cases (18.6%), it worked metaphorically (e.g. mass hysteria). Of the 17 references to ‘schizophrenia’, 9 (53%) were consistent with its original meaning as a psychiatric diagnosis. The remaining references included two songs describing symptoms consistent with dissociative identity disorder, categorised under the label of ‘schizophrenia’, and two songs using the term ‘schizophrenic’ as a marker of otherness in punk (Table 2).
Table 2 Examples of portrayals of schizophrenia in 129 Spanish punk songs related to psychotic symptoms/disorders
Thematic analysis
The analysis of songs in group 1 revealed two primary thematic clusters. The first cluster focused on clinical–therapeutic aspects (39.46% of references, n = 73), whereas the second was linked to the social dimension of psychosis (31.35% of references, n = 58). Within the latter, the following sub-themes emerged as particularly relevant: (a) associations between psychosis and violence, criminality and monstrosity; (b) the portrayal of people with psychosis as victims; and (c) the glorification of madness.
A third subgroup, named ‘mixed’, included references that combined themes from both the clinical–therapeutic and social dimensions (e.g. coercive treatment, which is relevant to both clinical–therapeutic and social perspectives on psychosis). The mixed themes represented 22.7% of references (n = 42).
Finally, a residual group of themes accounted for 6.49% of references (n = 12), with 10 references related to general perceptions of mental disorders (Table 3).
Table 3 Examples of views of mental disorders in Spanish punk songs with psychotic symptoms/disorders as central themes
Clinical–therapeutic themes
The majority of references within this theme focused on symptomatic aspects of psychosis (n = 31), followed by mentions of treatments (n = 16), hospital admission (n = 8) and substance use (n = 8).
In terms of symptoms, song lyrics often emphasised suffering, highlighting fear and anguish. Notably, two songs explicitly connected psychosis with suicidal behaviour. References to treatments were predominantly negative and superficial, often stereotyped without delving into their specific characteristics, techniques or effects.
Psychiatric hospital was portrayed as a place of discomfort and suffering, primarily characterised by a loss of freedom in a repressive environment of confinement, isolation, coercion and restrictions.
Concerning the relationship between psychosis and substance use, most references linked psychotic symptoms to acute intoxication or withdrawal. For instance, in the song ‘Paranoia’ (Kaótiko, 2003), the effects of cocaine use are described: ‘drug dealers chase me, a line here. People look at me strangely, they chase me here, though it might just be paranoia’. Similarly, ‘Txus’ (La Polla Records, 1984) describes psychotic symptoms caused by alcohol withdrawal: ‘Txus is an alcoholic, Txus is nervous, he has hallucinations, boiling alcohol comes out of his shower’.
The social dimension of psychosis
In the songs from group 1, 8.86% (n = 7) of references focused on the social impact of schizophrenia and other psychoses, highlighting issues such as rejection, incomprehension, withdrawal and loneliness (Supplementary Material 2).
A total of 76 references were made regarding perceptions of psychosis and those affected by it (Table 4). Of these, 46.05% (n = 35) conveyed neutral views of psychotic disorders, primarily emphasising the suffering of individuals and portraying them as victims of illness, society or psychiatry. A further 39.47% (n = 30) expressed negative views, often associating psychosis with violence or criminality. Only 14.47% (n = 11) conveyed positive views. Positive depictions framed ‘madness’ as freedom – including liberation from social norms – creativity, wisdom or an escape from unbearable reality (Table 4).
Table 4 Examples of perceptions about psychosis and those experiencing it in Spanish punk songs with psychotic symptoms/disorders as central themes
The majority of songs, however, portrayed individuals with psychosis in a negative light (17 songs, versus 3 songs with positive depictions) (Supplementary Material 3).
Finally, 52 references to psychiatric terms were found in the songs of group 2. Most references either strayed from psychiatric terminology or treated clinical terms neutrally (69.23%); one-third were pejorative (30.77%, n = 16), with none positive.
Discussion
The broader media landscape of mental illness portrayals
Subcultural expressions often differ from mainstream narratives, yet Spanish punk simultaneously reinforces and resists dominant media depictions of psychosis.
In film and television, psychosis is frequently tied to violence, unpredictability and social marginalisation. Reference Camp, Webster, Coverdale, Coverdale and Nairn6–Reference Wahl and Kaye8 In American prime time television, for instance, up to 72% of mentally ill characters are portrayed as violent, compared with far fewer ‘normal’ characters. Reference Signorielli18 News coverage amplifies this tendency, reinforcing the link between mental illness and danger. Reference Knoll, Annas, Gold and Simon19
Other media portrayals infantilise those affected, casting them as childlike, incapable of independence or objects of ridicule. Reference Sieff20 Psychiatric terminology and derogatory slang also permeate children’s content, Reference Wahl21,Reference Lawson and Fouts22 where labels like ‘crazy’, ‘nuts’ or ‘loony’ discredit characters and shape early social perceptions.
In news and social media, diagnostic terms like schizophrenia are often used metaphorically, detached from clinical meaning, Reference Ma23 a trivialisation that normalises stigma and reinforces misconceptions.
Additionally, cinema has perpetuated the contrasting trope of the ‘mad genius’, linking creativity or brilliance to mental illness. Reference Rosen, Walter, Politis and Shortland24
These polarised imaginaries – violent villain versus gifted outsider – form the backdrop against which punk representations emerge.
Representation of psychotic disorders in Spanish punk
Before turning to the thematic analysis, a note on terminology is required. In this discussion, expressions such as ‘psychosis-related content’, ‘psychotic disorders and symptoms’ and ‘madness’ are used flexibly. ‘Psychotic disorders and symptoms’ anchors clinical specificity; ‘psychosis-related content’ designates the broader corpus where psychiatric language appears; and ‘madness’ captures metaphorical, symbolic and ideological deployments. This elasticity avoids redundancy while reflecting the multiple registers through which culture encodes mental difference.
Symbolic function of psychosis in cultural discourses
Madness has long been a recurring theme in art, frequently deployed not merely as a descriptive category, but as a symbolic and ideological resource. Unlike other medical conditions, psychosis has historically been mobilised to interrogate boundaries between reason and unreason, order and disorder, conformity and resistance. This symbolic weight helps explain its polarised depictions, reflecting not only individual experiences, but also social anxieties about deviance and authority.
Salience of psychosis-related content in Spanish punk music
The finding that 2.8% of songs in our corpus reference psychosis is notable. Its significance, however, cannot be determined without comparative baselines across musical genres or media. Even in cinema, a field far more explored in relation to psychiatry, systematic prevalence estimates remain scarce. Thus, 2.8% should be read not as a measure of overall cultural attention, but as an internal index of salience within this specific corpus – useful for mapping clustering and thematic evolution.
What matters is less the proportion than the symbolic charge of such references: invoked sparingly, but when present, disproportionately shaping cultural imagination. As in other media, limited but highly charged representations of psychosis can eclipse more prevalent yet less culturally ‘spectacular’ psychiatric conditions.
Psychiatric discourse in cultural translation
Psychiatric discourse in Spanish punk unfolds along two complementary dimensions: linguistic–symbolic and diagnostic–conceptual. Both reflect how clinical categories migrate into the vernacular, losing technical precision but acquiring new cultural resonances. This contributes to a polysemic understanding of psychosis, where specific symptoms and experiences carry symbolic, cultural or subcultural significance while simultaneously reflecting broader societal misunderstandings.
Linguistic and symbolic diffusion
About 60% of songs referencing psychoses included descriptions of mental illness; the remainder used psychiatric terms in non-clinical contexts, illustrating the assimilation of psychiatric terminology into everyday language and cultural narratives.
Foucault described psychiatric language as ‘a monologue of reason about madness’, which marked a rupture in dialogue between madness and reason. Reference Foucault25 By contrast, Spanish punk reveals how psychiatric terms diffuse into vernacular speech and are reinterpreted as metaphors of deviance, identity or protest. In this slippage, terms circulate beyond their clinical contexts, acquiring new – often stigmatising or trivialising – connotations. Labels such as ‘schizophrenic’ often function as badges of alterity, marking boundaries between conformity and rebellion.
From a complementary angle, Hall’s theory of representation highlights how language codifies meaning into ‘conceptual maps’, shaping social understandings of categories. Reference Hall4 When terms such as ‘schizophrenic’ are used as generic negative adjectives, they reinforce distorted conceptual maps, reducing complex clinical realities to stigmatising labels.
Diagnostic elasticity and categorical slippage
Punk also reflects conceptual stretching. Schizophrenia and paranoia appear frequently, though often confused. Symptoms of dissociative identity disorder, for instance, were often mislabelled as ‘schizophrenia’ – a confusion also widespread in cinema, social media and lay discourse. Reference Angermeyer, Matschinger, Guimón, Fischer and Sartorius26–Reference Robinson, Turk, Jilka and Cella28 In the public imagination, schizophrenia often operates as a ‘catch-all’ label for any form of mental fragmentation.
The elasticity of psychiatric signifiers – terms that migrate, shift and accrue new meanings – extends beyond confusion to shifts in cultural weight.
A small subset of songs engaged with schizophrenia in unusually concrete biomedical terms, describing it as a ‘neuronal disorder’, ‘mental cancer’ or ‘deadly paranoia’. These metaphors suggest that psychiatric categories circulate in two directions at once: diluted into metaphors of deviance on the one hand, but also recharged with biomedical gravitas on the other. Such ambivalence exemplifies the cultural translation of psychiatric discourse, where technical categories oscillate between trivialisation, stigma and appeals to medical authority.
Language, stigma and cultural persistence
Linguistic diffusion and diagnostic elasticity contribute to stigma and the persistence of distorted social imaginaries. Social media research shows that the adjective ‘schizophrenic’ carries more negativity, sarcasm and medical inappropriateness than the noun ‘schizophrenia’. Reference Joseph, Tandon, Yang, Duckworth, Torous and Seidman29 This linguistic distinction illustrates how specific word choices contribute to processes of othering and to the entrenchment of stigma. When ‘schizophrenic’ is used as a generic negative adjective, it reinforces a simplified, stigmatised understanding that overshadows the complex medical reality. Moreover, conflating schizophrenia with dissociative identity disorder or using ‘paranoia’ in vague or polysemic ways illustrate how even subcultures reproduce broader societal and media-driven misunderstandings of mental illness. This indicates that such misconceptions are not only entrenched in mainstream discourse, but also resilient enough to circulate even within rebellious subcultures, showing how stigma operates across cultural boundaries.
Polarised depictions: victims and victimisers
Spanish punk lyrics reproduce this polarity in a subcultural register. Songs often linked psychoses with violence and criminality, as dangerous ‘otherness’ and a semiotic tool of rebellion. It aligns with the subcultural strategy of turning stigma into style, echoing Hebdige’s analysis of punk’s bricolage. Reference Hebdige30 Yet this resignification remains ambivalent: it destabilises psychiatric authority, but risks reinforcing negative associations.
Less frequently, songs highlight suffering, portraying those with psychoses as ‘victims’ of illness, society or psychiatry. Other pieces recast ‘madness’ as wisdom, freedom or creativity. This does not dissolve the polarity already entrenched in cinema and media, but reworks it: the ‘mad criminal’ and the ‘mad genius’ appear in punk too, although intensified through irony, provocation and anti-establishment rhetoric.
By presenting madness positively, punk challenges dominant stigmatising narratives – while still relying on the same polarising logic. Such representations reflect a wider cultural pattern where ‘the mad’ are rarely ordinary, but rather extreme: violent threats or tragic geniuses, villains or victims. Such dichotomies reduce complexity to stereotypes, reinforcing stigma but also serving as symbolic resources for protest.
Beyond this polarity, some songs linked psychosis to substance use, portraying psychiatric symptoms in neutral terms. Here madness is externalised, reframed as drug or alcohol effects, and decoupled from identity. Individuals are identified by addiction rather than psychotic experiences. Judgement targets addiction’s consequences, not psychosis itself. In some cases, rather than moral condemnation, the lyrics offer narrative observation or self-irony regarding the effects of consumption, highlighting socially disruptive behaviours or, alternatively, adopting a grotesque, provocative or light-hearted tone that renders hallucinations playful or absurd, without explicit moral weight attached to psychosis.
Depictions of psychotic features
Spanish punk songs reference disturbances in perception, emotion and thought, primarily depicting psychotic distress, anxiety and delusional thinking. Among perceptual symptoms, auditory hallucinations were the most prevalent, echoing English-language cinema. Reference Beachum31 This pattern may reflect broader cultural trends in the representation of psychosis across media.
The prominence of auditory phenomena appears to be shaped by both cultural conventions and symbolic resonance. In Spanish culture, ‘hearing voices’ is closely associated with popular perceptions of psychosis, whereas ‘having visions’ may carry broader, ambiguous meanings. This suggests that media and music selectively amplify certain symptoms, reinforcing culturally dominant semiotics of what psychosis ‘looks like’.
Beyond individual perceptual preferences, the conventions and constraints of different artistic media likely influence how psychotic experiences are depicted. These influences, however, do not rigidly determine their representation. Songs can portray both auditory and visual hallucinations, yet auditory phenomena, such as ‘hearing voices’, appear especially prominent, suggesting a culturally specific linkage between auditory phenomena and psychosis in the popular imagination. Visual experiences, in contrast, are often associated with broader imaginative and symbolic processes, rather than being directly linked to the category of the ‘madman’. Even in more complex audio-visual media, such as cinema, auditory experiences predominate. Reference Beachum31 This suggests that their prominence reflects not only medium affordances, perceptual salience and the author’s preferences, but also entrenched cultural meanings.
Overall, Spanish punk narratives participate in the selective cultural amplification of psychotic symptoms, privileging auditory phenomena as markers of psychosis. This highlights the interplay between cultural frameworks, symbolic conventions and artistic medium in shaping how psychotic experiences are represented and socially understood.
Negative portrayals of treatments and confinement
Spanish punk lyrics critique psychiatric institutions, involuntary confinement and medicalisation. This stance aligns with anti-psychiatry’s core tenets: mental illness as largely a social construct and psychiatric practices as instruments of social control. Similar critiques had already appeared in other popular music genres of the 1960s–1970s. Reference Spelman32,Reference Gios and Neto33
In this context, David Bowie’s ‘All the Madmen’ exemplifies Szasz’s ‘myth of mental illness’, Reference Szasz34 portraying madness as a conscious role and suggesting that those labelled ‘mad’ are saner than the so-called ‘normal’. The asylum is reframed as a sanctuary from a sick society. La Broma de SSatán’s ‘El Loco’ (1982) echoes this inversion, but in a more grotesque and jocular register: the psychiatric hospital is depicted as cruel, a site of experiments, physical harm and confinement. Yet the protagonist, after escaping, chooses to return – since the outside world proves even worse. This ironic twist parallels Bowie’s representation of the asylum.
The imagery of confinement, coercion and lost freedom in punk lyrics resonates with the historical public distrust of psychiatric practices and institutions. Reference Pavez, Saura and Marset13
Spanish punk music’s explicit and often raw critique of psychiatric treatments and confinement functions as a powerful subcultural amplification of long-standing societal grievances and the critiques articulated by the anti-psychiatry movement. With its inherent anti-establishment ethos, punk provides an accessible and resonant platform for these marginalised historical narratives. It enables critiques of authority to persist and reach a youth audience, serving as a form of cultural memory and ongoing protest.
Strengths and limitations of the study
This study combines frequency-based content analysis with thematic interpretation. Although not intended as a fully developed framework, it demonstrates how mixed methods can be applied to musical genres, artistic formats or subcultural expressions. Large-scale lyrical analysis paired with qualitative insights offers a model adaptable to other media, including social networks, now central in shaping perceptions.
As media consumption evolves, updating methodologies is crucial for future studies – for example, shifting from chart-based rankings (e.g. Billboard) to streaming metrics.
Our descriptive analysis does not address audience reception or composer intent, nor was it designed to generate theory. Reference Klin and Lemish35 Nonetheless, listening to a large data-set, rather than relying solely on transcripts, improved the accuracy of qualitative assessments.
Focusing on a single subculture reduced heterogeneity and improved internal consistency, but limits generalisability. Cultural biases in punk – such as gender imbalance and geographical specificity – must be considered. Yet, as Bestley argues, the punk ethos transcends local variations, especially in the post-internet era. Reference Bestley, Bull and Dines36 Thus, although context-specific, some findings may be transferable to comparative studies across populations and genres.
Implications
The polarised discourse on mental illness in Spanish punk echoes broader cultural logics that obscure everyday complexity, even when framed positively or romantically. Mental health conditions, however, are complex and cannot be reduced to simplistic notions of ‘good’ or ‘bad’. Recognising these patterns in cultural narratives can help identify stereotypes, prejudices and resistances that may arise during the diagnostic and therapeutic process with patients and their families.
About the authors
Fabian Pavez is a psychiatrist in the Lorca Mental Health Centre, Lorca, Spain. Erika Saura is a psychologist with the Association of Relatives and People with Mental Illness in Águilas and the Surrounding Area (AFEMAC), Águilas, Spain.
Supplementary material
The supplementary material is available online at https://doi.org/10.1192/bjb.2025.10175
Data availability
The data that support the findings of this study are available from the corresponding author on reasonable request.
Author contributions
F.P.: conceptualisation, project administration, methodology, data collection, data analysis, writing. E.S.: data collection, data analysis, writing – review and editing.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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