Are psychiatric diagnoses of psychosis scientific and useful? The case of schizophrenia

Linguistic and (micro)cultural differences in the global debate about re-naming 'schizophrenia': A mixed-methods survey from Switzerland

BACKGROUND AND HYPOTHESIS

This survey explores Swiss mental health professionals', users', and relatives' opinions on re-naming schizophrenia exploiting Switzerland's specific multilingualism to examine possible effects of linguistic and microcultural differences on the issue.

STUDY DESIGN

Opinions on 'schizophrenia' were collected using a self-rated online questionnaire incl. Freetext answers available in the three main Swiss languages, German, French and Italian. It was distributed to the main professional and self-help organizations in Switzerland between June and October 2021.

STUDY RESULTS

Overall, 449 persons completed the questionnaire, 263 in German, 172 in French and 14 in Italian. Of the total sample, 339 identified as mental health professionals, 81 as relatives and 29 as users. Considering the whole sample, almost half favored a name-change with a significant difference between stakeholder- and between language groups. Also, the name 'schizophrenia' was evaluated more critically than the diagnostic concept. Qualitative analysis of freetext answers showed a highly heterogenous argumentation, but no difference between language groups.

CONCLUSIONS

Our results suggest the attitude towards re-naming might itself be subject to (micro)cultural difference, and they highlight the nature of 'schizophrenia' as not only a scientific, but also a linguistic and cultural object. Such local factors ought to be taken into consideration in the global debate.

Context v. algorithm: evidence that a transdiagnostic framework of contextual clinical characterization is of more clinical value than categorical diagnosis

BACKGROUND

A transdiagnostic and contextual framework of 'clinical characterization', combining clinical, psychopathological, sociodemographic, etiological, and other personal contextual data, may add clinical value over and above categorical algorithm-based diagnosis.

METHODS

Prediction of need for care and health care outcomes was examined prospectively as a function of the contextual clinical characterization diagnostic framework in a prospective general population cohort (n = 6646 at baseline), interviewed four times between 2007 and 2018 (NEMESIS-2). Measures of need, service use, and use of medication were predicted as a function of any of 13 DSM-IV diagnoses, both separately and in combination with clinical characterization across multiple domains: social circumstances/demographics, symptom dimensions, physical health, clinical/etiological factors, staging, and polygenic risk scores (PRS). Effect sizes were expressed as population attributable fractions.

RESULTS

Any prediction of DSM-diagnosis in relation to need and outcome in separate models was entirely reducible to components of contextual clinical characterization in joint models, particularly the component of transdiagnostic symptom dimensions (a simple score of the number of anxiety, depression, mania, and psychosis symptoms) and staging (subthreshold, incidence, persistence), and to a lesser degree clinical factors (early adversity, family history, suicidality, slowness at interview, neuroticism, and extraversion), and sociodemographic factors. Clinical characterization components in combination predicted more than any component in isolation. PRS did not meaningfully contribute to any clinical characterization model.

CONCLUSION

A transdiagnostic framework of contextual clinical characterization is of more value to patients than a categorical system of algorithmic ordering of psychopathology.

"Manifestations of insanity": Kraepelin's final views on psychiatric nosology in their historical context

Emil Kraepelin, more than any other individual, has shaped the nature of our psychiatric diagnostic system. Kraepelin published his final contribution to psychiatric nosology as an essay in 1920, which both modified and explicated the conceptual foundation for this approach to diagnosis. This essay was a response to a new generation of psychiatrists, particularly Karl Jaspers, Karl Birnbaum, and Ernst Kretschmer, who each challenged Kraepelin's view that psychiatric disorders represent natural kinds, (i.e., truly distinct entities). They had argued for a structural analysis of psychosis stressing the impact of unique, personal attributes on the causes and clinical presentations of mental diseases. The authors give this text a close reading and conclude that it offers a final nuanced description of Kraepelin's advanced nosologic views and his emerging interest in life history and culture. Kraepelin held fast to his position that psychiatric disorders represented distinct natural kinds, but acknowledged that the distinctions between them were often obscured by personality, life experiences, and/or cultural effects. Kraepelin used several metaphors to illustrate his final views, that of an "organ register" being the most prominent. Psychiatric disorders, he postulated, belong to three registers, each with its own distinct clinical features and putative brain-based mechanisms. Published a century ago, this final synthesis of Kraepelin's views, a capstone to his career, raises central issues about the nature of psychiatric illness and the appropriate goals for psychiatric nosology. They are fertile issues for psychiatric research and practice today.

The Ins and Outs of 'Schizophrenia': Considering Diagnostic Terms as Ordinary Linguistic Expressions

Diagnostic terms in psychiatry like 'schizophrenia' and 'bipolar disorder' are deeply contested in the professional community, by mental health activists and the public. In this paper, we provide a theoretical framework for considering diagnostic terms as ordinary linguistic expressions and illustrate this approach by a corpus linguistic analysis of 'schizophrenia.' Our aim is to show how a focus on language itself can inform current and future debates about psychiatric terminology and provide new insights on relevant processes concerning their actual usage and change over time. We hope that this contributes to enhancing mutual understanding between different discourse spheres and stakeholders.

Prospective Long-Term Cohort Study of Subjects With First-Episode Psychosis Examining Eight Major Outcome Domains and Their Predictors: Study Protocol

Background: Our current ability to predict the long-term course and outcome of subjects with a first-episode of psychosis (FEP) is limited. To improve our understanding of the long-term outcomes of psychotic disorders and their determinants, we designed a follow-up study using a well-characterized sample of FEP and a multidimensional approach to the outcomes. The main goals were to characterize the long-term outcomes of psychotic disorders from a multidimensional perspective, to address the commonalities and differential characteristics of the outcomes, and to examine the common and specific predictors of each outcome domain. This article describes the rationale, methods, and design of a longitudinal and naturalistic study of subjects with epidemiologically defined first-admission psychosis. Methods: Eligible subjects were recruited from consecutive admissions between January 1990 and December 2009. Between January 2018 and June 2021, we sought to trace, re-contact, and re-interview the subjects to assess the clinical course, trajectories of symptoms and functioning, and the different outcomes of psychotic disorders. Since this is a naturalistic study, the research team will not interfere with the subjects' care and treatment. Predictors include antecedent variables, first-episode characteristics, and illness-related variables over the illness course. We assess eight outcome domains at follow-up: psychopathology, psychosocial functioning, self-rated personal recovery, self-rated quality of life, cognitive performance, neuromotor dysfunction, medical and psychiatric comorbidities, and mortality rate. The range of the follow-up period will be 10-31 years with an estimated mean of 20 years. We estimate that more than 50% of the baseline sample will be assessed at follow-up. Discussion: The study design was driven by the increasing need to refine the ability to predict the different clinical outcomes in FEP, and it aims to close current gaps in knowledge, with a broad approach to both the definition of outcomes and their determinants. To the best of our knowledge, this study is one of the few attempting to characterize the very long-term outcome of FEP and the only study addressing eight major outcome domains. We hope that this study helps to better characterize the long-term outcomes and their determinants, enabling better risk stratification and individually tailored, person-based interventions.

M. Staging of Schizophrenia With the Use of PANSS: An International Multi-Center Study

INTRODUCTION

A specific clinically relevant staging model for schizophrenia has not yet been developed. The aim of the current study was to evaluate the factor structure of the PANSS and develop such a staging method.

METHODS

Twenty-nine centers from 25 countries contributed 2358 patients aged 37.21 ± 11.87 years with schizophrenia. Analysis of covariance, Exploratory Factor Analysis, Discriminant Function Analysis, and inspection of resultant plots were performed.

RESULTS

Exploratory Factor Analysis returned 5 factors explaining 59% of the variance (positive, negative, excitement/hostility, depression/anxiety, and neurocognition). The staging model included 4 main stages with substages that were predominantly characterized by a single domain of symptoms (stage 1: positive; stages 2a and 2b: excitement/hostility; stage 3a and 3b: depression/anxiety; stage 4a and 4b: neurocognition). There were no differences between sexes. The Discriminant Function Analysis developed an algorithm that correctly classified >85% of patients.

DISCUSSION

This study elaborates a 5-factor solution and a clinical staging method for patients with schizophrenia. It is the largest study to address these issues among patients who are more likely to remain affiliated with mental health services for prolonged periods of time.

Segregating polymorphism in the NMDA receptor gene GRIN2A, schizotypy, and mental rotation among healthy individuals

Common alleles associated with psychiatric disorders are often regarded as deleterious genes that influence vulnerability to disease, but they may also be considered as mediators of variation in adaptively structured cognitive phenotypes among healthy individuals. The schizophrenia-associated gene GRIN2A (glutamate ionotropic receptor NMDA type subunit 2a) codes for a protein subunit of the NMDA (N-methyl-D-aspartate) receptor that underlies central aspects of human cognition. Pharmacological NMDA blockage recapitulates the major features of schizophrenia in human subjects, and represents a key model for the neurological basis of this disorder. We genotyped two functional GRIN2A polymorphisms in a large population of healthy individuals who were scored for schizotypy and mental imagery/manipulation (the mental rotation test). Rare-allele homozygosity of the promoter microsatellite rs3219790 was associated with high total schizotypy (after adjustment for multiple comparisons) and with enhanced mental rotation ability (nominally, but not after adjustment for multiple comparisons), among males. These findings provide preliminary evidence regarding a genetic basis to previous reports of enhanced mental imagery in schizophrenia and schizotypy. The results also suggest that some schizophrenia-related alleles may be subject to cognitive tradeoffs involving both positive and negative effects on psychological phenotypes, which may help to explain the maintenance of psychiatric-disorder risk alleles in human populations.

Dimensional symptom severity and global cognitive function predict subjective quality of life in patients with schizophrenia and healthy adults

Over the last several decades Quality of Life (QoL) has become increasingly important as an indicator of treatment outcomes; particularly in schizophrenia spectrum disorders because of its close association with functional disability. Numerous studies seeking to elucidate the factors that contribute to QoL in this population have implicated both symptom severity and cognition in determining QoL but the findings have been mixed. The critical factors that appear to impede the lack of consensus in the extant literature examining determinants of QoL include the heterogeneity of the samples and measures examined as well as medication effects across different studies. Thus, the present study sought to address some of these issues by examining the relationship between subjective QoL and both symptom severity and cognitive function in a relatively homogeneous patient sample of patients and a community control sample assessed for dimensional symptom severity. Our results suggest that both global cognitive function and psychiatric symptoms have a significant impact on the subjective QoL of both people with schizophrenia spectrum disorders and psychiatrically healthy adults. Specifically, we found that a global index of cognition as well as self-reported avolitional and depressive symptoms were significantly predictive of QoL in both samples. These findings highlight the importance of addressing cognitive, depressive and avolitional symptoms in the treatment of patients with schizophrenia spectrum disorders and suggest that improvements in these domains may have a meaningful impact on their overall QoL.

A study in the general population about sadness to disentangle the continuum from well-being to depressive disorders

OBJECTIVE

Sadness is both a common experience in general population and one of the main criteria of major depressive disorder (MDD). We tested the hypothesis of a depressive continuum using sadness as an intermediate experience between well-being and disorder.

METHODS

A French cross-sectional Mental Health survey in General Population interviewed 38,694 individuals. We examined prevalences and compared sociodemographic correlates and psychiatric disorders of individuals in 3 independent groups 1) MDD, 2) sadness without MDD, and 3) controls.

RESULTS

The prevalence of sadness was of 29.8% in the whole sample and of 93% in subjects suffering from MDD (n = 4976). The "sadness" group shared the same sociodemographic patterns as the "MDD" group. All psychiatric disorders assessed (i.e. bipolar disorder, anxiety disorder, alcohol use disorder, psychotic disorder and suicide attempts) were significantly associated with both "sadness" and "MDD" groups compared to "controls". Individuals with sadness, compared to those with MDD, were significantly less likely to meet the criteria for all psychiatric disorders. MDD's sensitivity of sadness was 94,2%.

LIMITATIONS

Even though we used a quota sampling method, the sample was not strictly representative of the general population.

CONCLUSION

Sadness validates the depressive continuum hypothesis, since it is more frequent in the general population than MDD itself and at the same time shares with MDD the same sociodemographic and clinical correlates. A gradual association from controls to MDD was observed for psychiatric comorbidities. Finally, the high sensitivity of sadness may suggest its use to screen at-risk individuals converting from well-being to full psychiatric disorders.

A crisis of meaning: can 'schizophrenia' survive in the 21st century?

Both within clinical and wider societal discourses, the term 'schizophrenia' has achieved considerable potency as a signifier, privileging particular conceptual frames for understanding and responding to mental distress. However, its status has been subject to instability, as it has lacked indisputable biological correlates that would anchor its place within the canon of medical diagnosis. Informed by a semiotic perspective, this paper focuses on its recent history: how 'schizophrenia' has been claimed, appropriated and contested-and how this connects with its earlier history of signification. It also explores how the dominance of this signifier has influenced the ways in which people with the diagnosis may find themselves constructed in their interactions with professionals, family and wider society, and hence how they may come to see themselves. It is argued that, from a point in the 1990s when 'schizophrenia' had achieved an almost iconic status, the term is now subject to greater instability, with concerns and challenges being raised from both within and outside psychiatry. On the one hand, this uncertainty has triggered a 'calls to arms' from those within the psychiatric establishment who see diagnoses such as 'schizophrenia' as crucial to their professional identity and status. On the other hand, this has created spaces for new conversations and alliances between elements within neurology, psychiatry, social work and other professions, and between these and service users. Some of these conversations are casting doubt on the validity and utility of 'schizophrenia' as a construct, and are beginning to posit alternative regimes of signification.

Using deep belief network modelling to characterize differences in brain morphometry in schizophrenia

Neuroimaging-based models contribute to increasing our understanding of schizophrenia pathophysiology and can reveal the underlying characteristics of this and other clinical conditions. However, the considerable variability in reported neuroimaging results mirrors the heterogeneity of the disorder. Machine learning methods capable of representing invariant features could circumvent this problem. In this structural MRI study, we trained a deep learning model known as deep belief network (DBN) to extract features from brain morphometry data and investigated its performance in discriminating between healthy controls (N = 83) and patients with schizophrenia (N = 143). We further analysed performance in classifying patients with a first-episode psychosis (N = 32). The DBN highlighted differences between classes, especially in the frontal, temporal, parietal, and insular cortices, and in some subcortical regions, including the corpus callosum, putamen, and cerebellum. The DBN was slightly more accurate as a classifier (accuracy = 73.6%) than the support vector machine (accuracy = 68.1%). Finally, the error rate of the DBN in classifying first-episode patients was 56.3%, indicating that the representations learned from patients with schizophrenia and healthy controls were not suitable to define these patients. Our data suggest that deep learning could improve our understanding of psychiatric disorders such as schizophrenia by improving neuromorphometric analyses.

Investigating the Lived Experience of Recovery in People Who Hear Voices

Although there is evidence of both clinical and personal recovery from distressing voices, the process of recovery over time is unclear. Narrative inquiry was used to investigate 11 voice-hearers' lived experience of recovery. After a period of despair/exhaustion, two recovery typologies emerged: (a) turning toward/empowerment, which involved developing a normalized account of voices, building voice-specific skills, integration of voices into daily life, and a transformation of identity, and (b) turning away/protective hibernation, which involved harnessing all available resources to survive the experience, with the importance of medication in recovery being emphasized. Results indicated the importance of services being sensitive and responsive to a person's recovery style at any given time and their readiness for change. Coming to hold a normalized account of voice-hearing and the self and witnessing of preferred narratives by others were essential in the more robust turning toward recovery typology.

Influencing Mental Health Policy and Planning: DSM–5 as a Disciplinary Challenge for Psychology

Since the appearance of DSM–5 in May 2013 a range of criticisms has emerged about its scientific and humanistic worthiness. An international network of protest is now evident, prompted in the run up to the publication of the document, by a letter of complaint (and offer of conciliation) from Division 32 of the American Psychological Association (the Society of Humanistic Psychologists). This article summarizes the criticisms evoked by DSM–5 and then moves to its main focus: the disciplinary challenge for psychology. The latter contains a number of aspects including the diversity, and thus sometimes incommensurability, of theoretical perspectives and the policy implications of moving from psychiatric diagnosis to psychological formulation. This shift from digital to analogue reasoning is less compatible with traditional legally based rationales of decision making in both the mental health and criminal justice systems than the digital logic. The article concludes with some suggestions of solutions to these challenges premised on critical realism.

Chronic exposure of mutant DISC1 mice to lead produces sex-dependent abnormalities consistent with schizophrenia and related mental disorders: a gene-environment interaction study

The glutamatergic hypothesis of schizophrenia suggests that hypoactivity of the N-methyl-D-aspartate receptor (NMDAR) is an important factor in the pathophysiology of schizophrenia and related mental disorders. The environmental neurotoxicant, lead (Pb(2+)), is a potent and selective antagonist of the NMDAR. Recent human studies have suggested an association between prenatal Pb(2+) exposure and the increased likelihood of schizophrenia later in life, possibly via interacting with genetic risk factors. In order to test this hypothesis, we examined the neurobehavioral consequences of interaction between Pb(2+) exposure and mutant disrupted in schizophrenia 1 (mDISC1), a risk factor for major psychiatric disorders. Mutant DISC1 and control mice born by the same dams were raised and maintained on a regular diet or a diet containing moderate levels of Pb(2+). Chronic, lifelong exposure of mDISC1 mice to Pb(2+) was not associated with gross developmental abnormalities but produced sex-dependent hyperactivity, exaggerated responses to the NMDAR antagonist, MK-801, mildly impaired prepulse inhibition of the acoustic startle, and enlarged lateral ventricles. Together, these findings support the hypothesis that environmental toxins could contribute to the pathogenesis of mental disease in susceptible individuals.

Evidence that a psychopathology interactome has diagnostic value, predicting clinical needs: an experience sampling study

BACKGROUND

For the purpose of diagnosis, psychopathology can be represented as categories of mental disorder, symptom dimensions or symptom networks. Also, psychopathology can be assessed at different levels of temporal resolution (monthly episodes, daily fluctuating symptoms, momentary fluctuating mental states). We tested the diagnostic value, in terms of prediction of treatment needs, of the combination of symptom networks and momentary assessment level.

METHOD

Fifty-seven patients with a psychotic disorder participated in an ESM study, capturing psychotic experiences, emotions and circumstances at 10 semi-random moments in the flow of daily life over a period of 6 days. Symptoms were assessed by interview with the Positive and Negative Syndrome Scale (PANSS); treatment needs were assessed using the Camberwell Assessment of Need (CAN).

RESULTS

Psychotic symptoms assessed with the PANSS (Clinical Psychotic Symptoms) were strongly associated with psychotic experiences assessed with ESM (Momentary Psychotic Experiences). However, the degree to which Momentary Psychotic Experiences manifested as Clinical Psychotic Symptoms was determined by level of momentary negative affect (higher levels increasing probability of Momentary Psychotic Experiences manifesting as Clinical Psychotic Symptoms), momentary positive affect (higher levels decreasing probability of Clinical Psychotic Symptoms), greater persistence of Momentary Psychotic Experiences (persistence predicting increased probability of Clinical Psychotic Symptoms) and momentary environmental stress associated with events and activities (higher levels increasing probability of Clinical Psychotic Symptoms). Similarly, the degree to which momentary visual or auditory hallucinations manifested as Clinical Psychotic Symptoms was strongly contingent on the level of accompanying momentary paranoid delusional ideation. Momentary Psychotic Experiences were associated with CAN unmet treatment needs, over and above PANSS measures of psychopathology, similarly moderated by momentary interactions with emotions and context.

CONCLUSION

The results suggest that psychopathology, represented as an interactome at the momentary level of temporal resolution, is informative in diagnosing clinical needs, over and above traditional symptom measures.

Differences in views of schizophrenia during medical education: a comparative study of 1st versus 5th-6th year Italian medical students

PURPOSE

This study explored medical students' causal explanations and views of schizophrenia, and whether they changed during medical education.

METHOD

The survey was carried out on medical students of the Second University of Naples, Italy, who attended their first-year and their fifth- or sixth-year of lessons. The 381 who accepted were asked to read a case-vignette describing a person who met the ICD-10 criteria for schizophrenia and then fill in the Opinions on mental illness Questionnaire.

RESULTS

The most frequently cited causes were psychological traumas (60%) and stress (56%), followed by misuse of street drugs (47%), and heredity (42%). 28% of students stated that persons with the disorder could be well again, and 28% that they were unpredictable. Labeling the case as "schizophrenia" and naming heredity among the causes were associated with pessimism about recovery and higher perception of social distance. First-year students more frequently reported psychological traumas among the causes (76 vs. 45%), and less frequently heredity (35 vs. 81%) and stress (42 vs. 69%), and they perceived less social distance from the "schizophrenics" than fifth/sixth-year students. In particular, 18% percent of first-year versus 38% of fifth/sixth-year students believed that these persons were kept at a distance by the other, and 45 versus 57% felt frightened by persons with the condition.

CONCLUSIONS

These results indicate a need to include education on stigma and recovery in schizophrenia in the training of medical students.

More than one century of schizophrenia: an evolving perspective

Schizophrenia is a very complex psychiatric disorder of unknown etiology, and there is controversy as to whether its name is even appropriate to describe the associated variety of clinical presentations and symptoms. Currently, the diagnosis is essentially based on clinical criteria. These enable a clinical profile to be recognized as encompassing positive symptoms, negative symptoms, disorganization of thinking and behavior, cognitive impairment, mood abnormalities, motor abnormalities, chronic clinical course, and incomplete remissions. The concept has evolved during the past century, and schizophrenia is currently questioned as a single disease entity. Established diagnostic criteria do not mirror the heterogeneity of the disorder. A strategy to deal with clinical heterogeneity in schizophrenia is, perhaps, the adoption of a classification system based on dimensions and stages. An additional strategy to deal with etiological and pathophysiological heterogeneity is to try to identify biomarkers, namely, on the basis of intermediate phenotypes. Despite extensive biological research, the biomarkers for schizophrenia are still lacking.

Differential diagnosis between non-pathological psychotic and spiritual experiences and mental disorders: a contribution from Latin American studies to the ICD-11

OBJECTIVE

To review research articles in psychiatry and psychology involving Latin American populations and/or produced by Latin American scholars to investigate the differential diagnosis between spiritual/anomalous experiences and mental disorders in order to contribute to the validity of the International Classification of Diseases towards its 11th edition in this area.

METHOD

We searched electronic databases (PubMed, PsycINFO, Scopus, and SciELO) using relevant keywords (possession, trance, religious experience, spiritual experience, latin, Brazil) for articles with original psychiatric and psychological data on spiritual experiences. We also analyzed the references of the articles found and contacted authors for additional references and data.

RESULTS

There is strong evidence that psychotic and anomalous experiences are frequent in the general population and that most of them are not related to psychotic disorders. Often, spiritual experiences involve non-pathological dissociative and psychotic experiences. Although spiritual experiences are not usually related to mental disorders, they may cause transient distress and are commonly reported by psychotic patients.

CONCLUSION

We propose some features that suggest the non-pathological nature of a spiritual experience: lack of suffering, lack of social or functional impairment, compatibility with the patient's cultural background and recognition by others, absence of psychiatric comorbidities, control over the experience, and personal growth over time.

The influence of causal explanations and diagnostic labeling on medical students' views of schizophrenia

PURPOSE

Negative attitudes toward mental illness among medical professionals can influence the quality of medical care they provide. The authors examined the impact of causal explanations and diagnostic labeling on medical students' views of schizophrenia.

METHOD

Medical students in their fifth and sixth years at the Second University of Naples (Italy) who attended lectures from April through June 2010 completed a self-report questionnaire regarding their beliefs about the mental disorder described (but not named) in a case vignette depicting a person who meets the International Classification of Diseases-10 criteria for schizophrenia.

RESULTS

Of the 232 students invited, 194 (84%) completed the questionnaire. Students most frequently cited heredity as the cause (81%), followed by stress (69%), psychological traumas (45%), and misuse of street drugs (44%). Most students (82%) labeled the case "schizophrenia"; a minority (24%) believed that persons with the case vignette disorder could be well again. Both labeling the case as "schizophrenia" and naming heredity as the cause were independently associated with pessimism about the possibility of recovery and with the perception that "others" keep their distance from persons with this diagnosis. Heredity was more frequently cited by respondents who labeled the case schizophrenia and was significantly associated with students' perception that people with this diagnosis are unpredictable.

CONCLUSIONS

These findings confirm that, in a sample of medical students, biogenetic causal explanations and diagnostic labeling have negative effects on beliefs about schizophrenia. They highlight the need to educate medical students about recovery from and stigma related to schizophrenia.

Schizophrenia, "Just the Facts" 6. Moving ahead with the schizophrenia concept: from the elephant to the mouse

The current construct of schizophrenia as a unitary disease is far from satisfactory, and is in need of reconceptualization. The first five papers in our "facts" series reviewed what is known about schizophrenia to date, and a limited number of key facts appear to stand out. Schizophrenia is characterized by persistent cognitive deficits, positive and negative symptoms typically beginning in youth, substantive heritability, and brain structural, functional and neurochemical alterations including dopaminergic dysregulation. Several pathophysiological models have been proposed with differing interpretations of the illness, like the fabled six blind Indian men groping different parts of an elephant coming up with different conclusions. However, accumulating knowledge is integrating the several extant models of schizophrenia etiopathogenesis into unifying constructs; we discuss an example, involving a neurodevelopmental imbalance in excitatory/inhibitory neural systems leading to impaired neural plasticity. This imbalance, which may be proximal to clinical manifestations, could result from a variety of genetic, epigenetic and environmental causes, as well as pathophysiological processes such as inflammation and oxidative stress. Such efforts to "connect the dots" (and visualizing the elephant) are still limited by the substantial clinical, pathological, and etiological heterogeneity of schizophrenia and its blurred boundaries with several other psychiatric disorders leading to a "fuzzy cluster" of overlapping syndromes, thereby reducing the content, discriminant and predictive validity of a unitary construct of this illness. The way ahead involves several key directions: a) choosing valid phenotype definitions increasingly derived from translational neuroscience; b) addressing clinical heterogeneity by a cross-diagnostic dimensional and a staging approach to psychopathology; c) addressing pathophysiological heterogeneity by elucidating independent families of "extended" intermediate phenotypes and pathophysiological processes (e.g. altered excitatory/inhibitory, salience or executive circuitries, oxidative stress systems) that traverse structural, functional, neurochemical and molecular domains; d) resolving etiologic heterogeneity by mapping genomic and environmental factors and their interactions to syndromal and specific pathophysiological signatures; e) separating causal factors from consequences and compensatory phenomena; and f) formulating or reformulating hypotheses that can be refuted/tested, perhaps in the mouse or other experimental models. These steps will likely lead to the current entity of schizophrenia being usefully deconstructed and reconfigured into phenotypically overlapping, but etiopathologically unique and empirically testable component entities (similar to mental retardation, epilepsy or cancer syndromes). The mouse may be the way to rescue the trapped elephant!