Diagnosis of Schizophrenia: Reliability of an Operationalized Approach to ‘Praecox-Feeling’

Abstract

Background: H.C. Rumke coined the term ‘praecox-feeling’ to denote a specific unease experienced by the clinician reflecting the ‘impossibility of empathy’ and ‘lack of exchange of affect’ that has been reported to occur early on when examining schizophrenia patients. There is ample evidence that praecox-feeling is still relevant in modern clinical practice. This study examined the reliability of operationalized praecox-feeling against the background of modern diagnostic criteria and assessment methods. Sampling and Method: 102 consecutively admitted patients (37 with a diagnosis of schizophrenia) were interviewed within 2 days of their admission to a university-affiliated acute psychiatric unit. This initial interview was observed by 5 psychiatrists who had never seen the patients before. The interview lasted 2 min and consisted of standard, non-specific questions. The observing clinicians independently rated the absence or presence of praecox-feeling for each patient at 30 s and 2 min after encountering the patients. A sixth psychiatrist then examined the patients using the SCID-DSM-IV and all available information to reach a best estimate DSM-IV diagnosis. Results: Measured against a research diagnosis, praecox-feeling had unsatisfactory sensitivity, specificity, positive and negative predictive values, and area under the receiver-operator curves. There was no significant difference between the 30 s and the 2 min ratings of any of the 5 clinicians. Of the socio-demographic and clinical characteristics, only early age of onset was significantly associated with praecox feeling for the majority of the raters. The raters’ length of clinical experience did not correlate with the accuracy of their praecox-feeling. Conclusions: Measured against a best estimate research diagnosis in this study, praecox-feeling had modest sensitivity and specificity. Diagnostic agreement with the modern gold standard diagnosis of schizophrenia for all raters of praecox-feeling was poor. Although praecox-feeling appears to be an unreliable diagnostic compass, several lines of evidence suggest that its existence in clinical practice cannot be denied, which underscores the importance of a subjective element of unknown composition, magnitude and reliability in the diagnostic process that deserves more attention.

Association between Clinician's Subjective Experience during Patient Evaluation and Psychiatric Diagnosis

“…Despite being used in everyday clinical practice [56,57], the concept of intuitive knowledge as put forth by classical psychopathology has not been empirically tested, except for the putative schizophrenia-specific ineffable intuition named ‘Praecox Gefühl[' 58], which has been the object of a few studies that gave inconclusive results [59,60,61]. In psychotherapy research, a number of studies attempted to explore the relationship between the therapist's feelings and the patient's diagnosis or symptoms [62,63,64,65,66,67].…”

Assessing Clinician's Subjective Experience during Interaction with Patients

“…In psychiatric literature, there are many terms that refer to this experience; the most popular and articulated conceptualizations are undoubtedly Rümke's Praecox Gefühl [9], Wyrsch's Diagnosis through Intuition [10], Minkowski's Diagnostic par Pénétration [11], Binswanger's Diagnosis through Feeling [12], and Tellenbach's Atmospheric Diagnosis [13]. Of these, only Rümke's Praecox Feeling was empirically tested, although with conflicting results: one study found a good diagnostic precision of such intuitive reasoning [14] whereas another yielded inconclusive findings [15]. These discrepant findings may be related to different definitions of the concept itself and to the methodological approaches used.…”

Discussing Rümke’s “Praecox Feeling” from the clinician’s experience of schizophrenic contact

“…To unfold this paradox, we wanted to submit the account of a clinical encounter from the perspective of the clinician. Very few recent studies had been made to explore the reliability and validity of Praecox Feeling as a diagnostic tool in clinical practice (Wiggins, 1987;Grube, 2006;Ungvari, 2010). These researches had intended to compare Praecox…”