LAUSR

Just prior to a tsunami, the water curiously recedes – and on occasion, this draws unsuspecting onlookers to explore the beach further and venture inquisitively towards imminent danger. This early warning sign is particularly treacherous because it is counterintuitive, contrasting to the fearful roar that precedes a wall of fast approaching water. However, the tsunami itself is also only a sign, and meanwhile the event that it represents – an earthquake, quietly tears apart the seabed deep beneath the ocean’s surface. Analogous to this, the foundation of psychiatry is experiencing its own earthquake, and the early warning signs – signalling that there are deep-seated fractures within the structure of our classificatory systems are already here. In psychiatry, the description ‘early warning sign’ usually refers to the incipience of mental illness – such as bipolar disorder (1). Being attuned to such signals is helpful in clinical practice for detecting the emergence of an episode of illness (e.g. depression or mania) – either de novo or when the individual relapses. However, in this editorial, we employ the term more broadly – to describe the failure of current taxonomies to properly accommodate mixed states. We contend that mixed states simply do not fit – and argue, that this inability to adequately incorporate mixed states is a consequence of it simply not being possible. This is because the basis upon which our classificatory models have been devised is fundamentally flawed. This criticism applies to both DSM and ICD, but for brevity we’ll use DSM-5 as an exemplar.