Typifications: The First Step for Clinical Diagnosis in Psychiatry

Background: Classical psychopathology greatly valued the interaction between clinician and patient, and assigned to the clinician's subjective experience a significant role in the diagnostic process. Psychoanalysis, too, ascribed a privileged position to the clinician's feelings and empathic participation in the assessment and deep understanding of the patient. This study aimed at testing the traditional, though still relatively unexplored empirically, tenet that particular diagnostic groups elicit distinct and diagnostically useful reactions from clinicians. Sampling and Methods: The study was performed in several psychiatric inpatient and outpatient units in Rome, Italy. The clinicians completed the Assessment of Clinician's Subjective Experience (ACSE) questionnaire and other standardized assessment instruments when they evaluated a previously unknown patient. All adult patients diagnosed with schizophrenia (n = 119), cluster B personality disorder (n = 114), manic or mixed bipolar I episode (n = 59), and unipolar depression or anxiety disorder (n = 130) were included in the study, for a total of 422 patients evaluated by 35 clinicians. Results: We found a significant and theoretically consistent relationship between the clinicians' pattern of subjective experience during the first visit and patients' clinical diagnoses. Patients with unipolar depression/anxiety showed significantly lower scores than the other groups on all ACSE scales except engagement; patients with schizophrenia displayed significantly higher scores than the other groups on difficulty in attunement, and significantly higher scores than patients with cluster B personality disorder on impotence. Compared with the other groups, the patients with cluster B personality disorder displayed significantly lower scores on engagement, and significantly higher scores on disconfirmation. In multivariate models controlling for patient's age and education, symptom severity, clinician's sex, duration of visit and setting, diagnosis remained a significant predictor of scores on all ACSE scales except for impotence. Conclusions: The main limitations of the study are its reliance on clinical diagnoses and the non-independence of assessments. Further studies based on diagnoses made by a third observer through standardized instruments are needed to provide a most stringent test of the hypothesis that different diagnoses are associated with distinct profiles of clinicians' subjective experience. This study provided intriguing, though preliminary, evidence that the clinician's subjective experience may play a useful role in the diagnostic process. Time may have come to reintroduce the concept of intersubjectivity at the core of the diagnostic process.

Section: Discussionmentioning

confidence: 84%

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

Pallagrosi

Fonzi²,

Picardi³

et al. 2016

“…Essentially, the intuitive process implied by the author is the one accurately described by Schwartz and Wiggins [32]. That is, the clinician’s act of rapidly typifying the clinical picture through an implicit comparison between the gestalt of the actual patient and the gestalt of all the schizophrenic patients examined throughout the course of his/her career.…”

Section: The Praecox Feeling According To Rümkementioning

confidence: 99%

“…The second is the explicit reference of the author to the use of praecox feeling only by “very experienced clinicians” [22]. It seems clear that a perception which is mostly based on the amount of clinical experience is better used by clinicians who have encountered a great number of patients [32]. On the contrary, the clinician’s sensitivity to the autistic nucleus of the schizophrenic patient seems to primarily rely on his/her human empathic capacities, which do not definitively arise from the clinical experience.…”

Section: The Praecox Feeling According To Rümkementioning

confidence: 99%

On the Concept of Praecox Feeling

Pallagrosi

Fonzi

2018

Despite the development and widespread diffusion of modern nosographic systems, the diagnosis of schizophrenia continues to raise several epistemological issues. To address these issues, a number of researchers are currently pursuing the possibility of an integration between reliable, objective approaches and the intersubjective perspective in the clinical encounter. In the present article, we discuss Rümke’s popular concept of praecox feeling, as introduced in 1941 and re-elaborated over the following 20 years. Our aim was to thoroughly analyze the author’s original formulation and to identify the connections between his thinking and certain psychopathological developments, epistemological issues, and research perspectives on schizophrenia. The praecox feeling is presented by Rümke as a sensitive diagnostic tool for schizophrenia that is rooted in the peculiar subjective experience of the clinician when encountering a schizophrenic patient. This experience seems to be characterized by two essential dimensions: a subjective one, which reflects the failure of a clinician’s empathic effort due to a fundamental alteration of the intersubjective space, a phenomenon related to schizophrenic autism, and a gestaltic, objective one, which is grounded in the clinician’s implicit typifying process as a consequence of collecting recurrent clinical observations over the course of his/her professional experience. According to Rümke, the diagnostic use of the praecox feeling should be limited to the acute phases of the schizophrenic process, as the clinician’s experience of an intersubjective struggle is attenuated in interactions with older, chronic patients. The multifaceted nature of Rümke’s proposal seems to have contributed to some theoretical critiques and to inconclusive results from empirical investigations, leading to a progressive devaluation of the scientific and diagnostic validity of praecox feeling. The present analysis of the original concept suggests that a renewed research interest in the role of the clinician’s subjective experience with regard to the schizophrenic patient could be helpful.

“…The few attempts to comprehend PF have mostly been made by phenomenologically-oriented psychiatrists who have provided fascinating descriptions and hypotheses of the importance of intuition in the first few minutes of the encounter between the schizophrenia patient and the psychiatrist [8,14,19,[30][31][32][33][34][35] . Trying to capture the underlying reason for PF, clinicians mentioned a lack of resonance, altered mimics and psychomotorium, alien world, glass wall, contact and 'feeling uncomfortable' (Unheimlichkeitsgefühl) [14] .…”

Section: Praecox-feeling In Modern Psychiatrymentioning

confidence: 99%

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

Ungvári

Xiang²,

Yu³

et al. 2010

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.