Herman van Praag has made major contributions to the scientific and conceptual development of psychiatry. Despite progress in delineating reliable diagnostic criteria, our classification system ignores clinical insights available from patients' subjective experiences of illness. Hence a ‘coarsening of diagnosis’ has occurred, weakening the nosologic infrastructure of scientific psychiatry. This paper will discuss these ideas and emphasize the central role of psychopharmacology in advancing psychiatry, with lithium's discovery as a paradigm.

The earliest signs and symptoms of manic relapse in eight bipolar patients after lithium discontinuation were changes in talkativeness, motor performance, self-confidence and sleep pattern; only two patients reported a change in mood. These changes were initially subtle and did not occur in patients who stayed well after stopping lithium. The lack of affective symptoms might result in clinicians ascribing the changes to the removal of the sedative and cognitive slowing properties of lithium, rather than signs of an impending relapse; similar changes may well occur in patients whose relapse is not associated with lithium discontinuation. Prompt early treatment with lithium (and additional thioridazine in some cases) resulted in only two patients requiring readmission, both for ten days. It is concluded that such symptoms may indicate an impending relapse and prompt treatment is recommended.