Praecox feeling is a characteristic feeling of bizarreness or unease that a psychiatrist experiences when encountering an individual with schizophrenia. Classically, it was considered an important feature of schizophrenia diagnosis. However, since the movement toward operational diagnostic methods in the late 1970s, it has fallen out of use. It is considered arbitrary, subjective, and unscientific by many physicians and is not included in contemporary diagnostic criteria or research.1

According to Dutch psychoanalyst and psychiatrist Henricus Cornelius Rümke, this feeling or knowing can be experienced even before a patient has actually spoken. If the clinician is attentive, they can feel “the inability to come into contact with [the patient’s] personality as a whole,”2 noticing oddities in body language, tone of voice, attitude, and motor behaviors. The clinician may also notice a general feeling of peculiarity, lack of empathy, and affective disturbances in the patient.1,2

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The Role of Praecox Feeling in the Clinical Approach to Schizophrenia Diagnosis

Rümke wasn’t alone in his reliance on praecox feeling. Other clinicians have also acknowledged its role in diagnosing schizophrenia. Tellenbach referred to it as an “atmospheric diagnosis,” while Krauss and Wyrsch described a “diagnosis through intuition.”1 Praecox feeling may be the answer to what some call “the mystery of psychiatric diagnosis,” which refers to a clinician’s ability to rapidly diagnose a patient in just a few minutes, sometimes in less than 30 seconds.3 A 2012 study found that psychiatrists who spent more time thinking and using logic and rationale for diagnosis were less accurate than those who relied on their intuition.4

While praecox feeling is based on the physician’s global perception of the individual, it does not stop at intersubjectivity. Once praecox feeling is established, it can be backed by individual symptoms and objective diagnostic criteria.2 Still, praecox feeling has been heavily stigmatized by antipsychiatry movements, which claim that psychiatric diagnoses are arbitrary.1

Prevalence of Praecox Feeling in Contemporary Research and Diagnostic Methods

Due to such stigmatization and trivialization, praecox feeling is almost entirely unaccounted for in contemporary diagnostic methods. The closest thing to praecox feeling was “bizarre delusion” in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) and Fourth Edition (DSM-IV) but it has since been removed and is not included in the DSM-V.5-7

Praecox feeling has been ignored in contemporary schizophrenia research as well. Few empirical studies have been conducted on the role of praecox feeling in the clinical diagnosis of schizophrenia. Still, there exists sufficient evidence that praecox feeling plays a role in the diagnostic process. An extensive survey published in Science in 1973 revealed that “poor rapport” was one of the 12 most common and reliable signs used when making a schizophrenia diagnosis.8

Three studies have been conducted solely to explore the prevalence of praecox feeling in schizophrenia diagnosis. All showed a high prevalence (at least 82%) of praecox feeling even in those studies conducted after the popularization of operationalized diagnostic tools in the 1980s.1

Two more recent studies have examined the sensitivity of praecox feeling in the diagnostic process. The first study focused on 1 physician who saw 67 new patients for which he rated praecox feeling on a scale ranging from “not present” to “high” within the first few minutes of the clinical interview. This information was compared with diagnostic results from the International Statistical Classification of Diseases and Related Health Problems, 10th revision, and DSM-IV. His praecox feeling showed both high sensitivity (0.88 and 0.84) and high positive predictive power (0.94 and 0.93).9

The second study looked at praecox feeling in 5 different clinicians who saw 102 new patients. Each clinician rated the absence or presence of praecox feeling in the first 30 seconds and 2 minutes of the interview. The results of this study showed variability among physicians with sensitivity ranging from 0.23 and 0.86 and a positive predictive power between 0.35 and 0.40. However, the negative predictive power was higher with ranges from 0.66 to 0.78.10

Conclusion

The results of the aforementioned studies are not enough to draw conclusions regarding the role, prevalence, and validity of praecox feeling in the clinical diagnostic process. That said, while there may not be sufficient evidence to consider it valid clinical diagnostic criteria, it still appears to play a role in the clinical decision-making process and should not be trivialized or stigmatized. It is not fully subjective and does rely on objective data, such as the patient’s behaviors and body language. Further research on prevalence and reliability is needed to determine usefulness.

References

1. Goze T, Moskalewicz M, Schwartz MA, Naudin J, Micoulaud-Franchi JA, Cermolacce, M. Reassessing “Praecox Feeling” in diagnostic decision making in schizophrenia: a critical review [published online November 23]. Schizophr Bull. doi: 10.1093/schbul/sby172

2. Pallagrosi M, Fonzi L. On the Concept of praecox feeling. Psychopathology. 2018;51:353-361.

3. Schwartz MA, Wiggins OP. Typifications: the first step for clinical diagnosis in psychiatry. The J Nerv Ment Dis. 1987;175(2):65-77.

4. Aarts AA, Witteman CLM, Souren PM, Egger JIM. Associations between psychologists’ thinking styles and accuracy on a diagnostic clarification task. Synthese. 2012;S1:119-30.

5. Cermolacce M, Sass L, Parnas J. What is bizarre in bizarre delusions? A critical review. Schizophr Bull. 2010;36: 667–679.

6. Sass LA, Byrom G. Self-disturbance and the Bizarre: on incomprehensibility in schizophrenic delusions. Psychopathology. 2015;48:293–300.

7. Tandon R, Gaebel W, Barch DM, et al. Definition and description of schizophrenia in the DSM-5. Schizophr Res. 2013;150:3–10.

8. Carpenter WT Jr, Strauss JS, Bartko JJ. Flexible system for the diagnosis of schizophrenia: report from the WHO international pilot study of schizophrenia. Science. 1973 Dec; 182(4118):1275–8.

9. Grube M. Towards an empirically based validation of intuitive diagnostic: Rümke’s ‘Praecox Feeling’ across the schizophrenia spectrum: preliminary results. Psychopathology. 2006;39(5):209–17.

10. Ungvari GS, Xiang YT, Hong Y, Leung HC, Chiu HF. Diagnosis of schizophrenia: reliability of an operationalized approach to ‘Praecox-Feeling’. Psychopathology. 2010;43(5): 292–9.