Towards an Empirically Based Validation of Intuitive Diagnostic: Rümke’s ‘Praecox Feeling’ across the Schizophrenia Spectrum: Preliminary Results

Abstract

Background: The early identification of schizophrenia is important in establishing an adequate therapeutic intervention, especially in emergency situations. Intuitive reasoning is often necessary because a standardized classification according to ICD-10 or DSM-IV criteria is not suitable in these complex, and often changing, settings. The process of recognizing the specific schizophrenic structure in an intuitive way by an experienced psychiatrist was named ‘praecox feeling’ by the Dutch psychiatrist Rümke in 1941. Sampling and Methods: To evaluate the diagnostic quality of this kind of intuitive clinical approach we investigated 67 previously unknown patients. All patients displayed acute psychotic symptoms like paranoid delusions and hallucinations belonging to the schizophrenic spectrum. The first interview by an experienced psychiatrist included only the present state psychopathology. Data referring to the course of the illness or medication or family history of schizophrenia were explored later by other independent staff members who were blind to the aim of the investigation. The intensity of the ‘praecox feeling’ was rated in four degrees: not present – mild – moderate – high. At the end of the inpatient period a standardized diagnostic classification according to ICD-10 and DSM-IV classification was carried out by independent raters. Results: Compared to the standardized diagnostic classification the precision of the intuitive reasoning was remarkably high with a sensitivity of about 0.85, a specificity of about 0.80, a positive predictive power of about 0.90, and a negative predictive power of about 0.65 depending on the standardized system used. Cognitive impairment, affective disturbances, disturbed self-perception, and reduced communication skills all correlated with intensity of ‘praecox feeling’. The single variable ‘affective disturbances’ had the highest impact on the intensity of ‘praecox feeling’ in an ordinal regression analysis. Furthermore a high intensity of ‘praecox feeling’ strongly correlated with a hereditary predisposition to schizophrenia. Neither the severity of the mental illness nor extrapyramidal side effects of the medication correlated with the intensity of ‘praecox feeling’. Conclusion: Our work can possibly help in contributing to reflection on our diagnostic practices and help to make the various factors involved in establishing diagnoses apparent.

Assessing Clinician's Subjective Experience during Interaction with Patients

“…We specifically examined the clinician's behavioral and emotional responses to the clinical evaluation of a new patient, which is a situation where intuitive and prereflexive reasoning play a substantial role, as a clinical diagnosis has to be made in a relatively short time. We derived our attempt mainly from the phenomenological theories regarding the importance of the subjective elements contributing to the ‘first clinical impression' [9,10,11,12,14,27]. …”

“…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.…”

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].…”

Empathy in schizophrenia: impaired resonance

“…We assume that this phenomenon is based on reduced resonance. This intuitive reasoning based on subliminal information is still used today by some psychiatrists in daily practice in addition to standardized diagnostic classification [21]. Impaired empathy has recently been assumed to be involved in schizophrenia [2,19,51,54].…”