Discrimination between schizophrenia and other psychotic conditions by clinician's difficulty in attunement: a reappraisal of the Praecox Feeling concept.

Abstract

Introduction: In the 1940s, Henricus Cornelius Rümke introduced the concept of Praecox Feeling (PF), a multifaceted clinician's intuition about the nuclear essence of schizophrenia that may play a role in the diagnostic process. Many classical and contemporary psychopathologists have devoted attention to this concept and the issue of intuitive diagnosis of schizophrenia. However, so far very little empirical research was carried out on this topic. This study aimed at testing the hypothesis that the empathic failure described by Rümke as a major experiential dimension underlying the PF as measured by the ACSE Difficulty in Attunement scale can discriminate between schizophrenia and the other psychotic conditions.

Methods: The study involved 49 clinicians and 326 patients (schizophrenia N = 161, schizoaffective disorder N = 47, delusional disorder N = 35, psychotic mood disorder N = 83) in several psychiatric inpatient and outpatient units. When they saw a new patient, the clinicians completed the Assessment of Clinician's Subjective Experience questionnaire (ACSE) and the 24-item Brief Psychiatric Rating Scale (BPRS).

Results: While no significant finding was observed in outpatients, several significant between-group differences in ACSE scores were found in inpatients. In multivariate analysis controlling for patient's sex, age, educational level, and clinical severity as measured by BPRS total score, we found that clinicians reported higher levels of Impotence with patients affected by schizoaffective disorder and schizophrenia than with patients affected by psychotic mood disorder, and that clinicians reported higher levels of Difficulty in Attunement with patients affected by schizophrenia than with patients affected by delusional disorder and psychotic mood disorder.

Discussion: Although our findings should be interpreted with caution due some study limitations, they corroborate the notion that the clinician's feelings, and in particular empathic attunement and its disruptions, play a role in the diagnosis of schizophrenia. They provide preliminary support for Rümke's hypothesis that the PF may help distinguishing between clinically overlapping psychotic conditions. Overall, this study highlights the importance for psychiatry to embrace the relational dimension of the clinical encounter, and to recognize the value of the clinician's subjective participation within the clinical relationship itself.