A Disappearing Heritage

The Clinical Core of Schizophrenia

Josef Parnas

Disclosures

Schizophr Bull. 2011;37(6):1121-1130. 

In This Article

The Ill-Famed "Praecox-Feeling"

We will briefly address here the notion of "Praecox Gefühl", now antiquated and out of use, but nonetheless important for an understanding of the attempts to capture the clinical core of schizophrenia. The expression "praecox feeling" was coined by a Dutch psychiatrist, Rümke[42] who claimed that the diagnosis of schizophrenia was sometimes bolstered by a (more or less) ineffable intuition, probably based on a fundamental inaccessibility of the patient. Rümke's idea was almost as old as the concept of schizophrenia itself, and it was widely described in schizophrenia research. Similar terms included "diagnostic par pénétration,"[20] "diagnosis through intuition,"[43] or "atmospheric diagnosis".[44] The term "intuition" refers in phenomenology to a direct apprehension of an object or state of affairs, an apprehension that is not mediated by reflection. Müller-Suur[45] emphasized that the original intuition of incomprehensibility could be strengthened by a more reflective diagnostic apprehension: the incomprehensibility in schizophrenia is not something vague but something "definitely incomprehensible". No matter how well we come to know the patient's psychopathology and personal history, we remain confronted with a residuum of definite incomprehensibility. Wyrsch[43] suggested that what was here at play was a perception of an existential change. We perceive a transformation of the modality of being into an order of its own (eine Daseinsweise). What is incomprehensible, but nonconceptually grasped by a clinician, are altered basic structures of the "being-in-the-world", eg, the temporality and spatiality of being, the self, and basic self-world relatedness. These structures are not concrete, perceivable objects, like symptoms or signs; they are constitutive, ie, functioning as preconceptual conditions of our existence.[46](p48) The clinicians may perceive such changes in a nonconceptual mode, a type of experience that is difficult to convey in a linguistic propositional (sentence-like) format.

The validity of the intuitive diagnosis by an experienced clinician was documented in a spectacular way by Gottesman and Shields[47] in their seminal Maudsley schizophrenia twin study. The study showed concordance rates among MZ- and DZ-co-twins of the schizophrenic probands to be around 50% and 10%, respectively. They invited an outsider, a renowned Swedish expert on the schizophrenia spectrum conditions (schizoidia), professor Essen-Möller, to blindly diagnose the vignettes of their sample, asking for a binary classification: within or outside the schizophrenia spectrum?. Essen-Möller's schizophrenia spectrum cases demonstrated MZ a concordance rate of approximately 90%, without inflating the corresponding DZ concordance. Gottesman and Shields concluded that it was the most successful attempt of validation of the schizophrenia spectrum concept. However, Essen-Möller was not able to explicate his diagnostic performance in a descriptive, symptom-list manner. His performance was, most likely, an instance of Gestalt–or pattern-recognition, executed by an extremely skilled and knowledgeable clinician.

The concept of praecox feeling gradually lost its theoretical and phenomenological baggage, and became trivialized into a notion of "instant" or "first 3 minutes" diagnosis. Eventually, it lost all clinical significance with the introduction of the operational criteria for diagnosis. In a theoretical debate preceding the formation of the DSM-III, the "praecox-feeling" was considered as emblem of psychiatry's subjectivism, incompatible with its scientific aspirations. The term also served as ammunition for antipsychiatrists who pointed out the arbitrariness and the excessive power of psychiatric labeling.

There are certain misunderstandings, which, in my view, obscure a potential epistemological import of the notion of praecox feeling. The intuition arises mainly passively; it cannot be instigated at will. It needs not to be restricted to the first minutes of the encounter with the patient, but may arise at any moment throughout the interview. It may arise seemingly unprovoked or provoked by a single gesture, a facial expression, or something uttered by the patient, a something that changes the entire apprehension of the patient because it changes the significance of the perceived Gestalt. In such cases it resembles the experience of aspect dawning (like, when looking at an ambiguous figure, eg, a duck–rabbit, you start to see the rabbit and then, your way of viewing somehow changes, and now, suddenly, you see the duck.[48,193c] There is a change in the perception of the entire Gestalt despite no or minimal changes at the sensory level.

In an ordinary diagnostic situation, there is no extra intuition on the top of a Gestalt-recognition supported by the symptom/sign-based information. The passively experienced intuitive diagnostic hunch was never supposed to be applied as an autonomous classificatory arbiter in a random population of patients. Rather, it was believed to sometimes help the clinician in distinguishing between schizophrenia and other types of psychosis (schizophrenia vs "pseudoschizophrenia" [The Anglophone concept of a "schizophrenia like" psychosis [eg, in epilepsy], ie, a psychosis with hallucinations and delusions, was certainly not "schizophrenia-like" in the European perspective, where the specificity of schizophrenia was dependent on the clinical core features, rather than on the positive psychotic symptoms.]). It is obvious that praecox-feeling, for several reasons, cannot belong to the diagnostic tools in clinical psychiatry. That does not cancel its clinical reality or its conceptual/epistemological import for schizophrenia research.

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