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Prof. Dr. H.C. RUMKE Het Kernsymptoom der Schizophrenie en het Praecoxgevoel* (The nuclear symptom of schizophrenia and the praecoxfeeling) (1941) How does the psychiatrist diagnose schizophrenia? This question remains of crucial importance, in spite of the fact that schizophrenia is one of the commonest mental disorders about which there is a wealth of literature, and which is diagnosed daily by most psychiatrists. No answer is available as yet, and in this essay a definite solution cannot be given either. The difficulties surrounding the clinical diagnosis of schizophrenia crop up repeatedly during the clinical process, and disagreement between clinicians is © K. G. Rumke, ‘Persoonliheid en Prychotherapie (persorality and paychotherspy’, in Studies en Voondrachien over Peychinirie Amasterdam: Scheltema & Holkema, 1548), 411-428. * Fist published in Sadie en Voordrachen ver Pechierie (Amsterdam: Scheltema & Holkema, 1948), 33-58. Reproduced in English by kind permission of Bobs, Scheltema & Holkema, B.V. SCHIZOPHRENIA AND THE PRAECOXFEELING 335 not at all uncommon, The diagnostic uncertainties are poignantly illustrated by the discrepancies in statistical data regarding the outcome of schizophrenia treatment. By now one may assume that electroshock procedures in all well- equipped hospitals are similar. Therefore, the huge differences in remission rates have to be due mainly to differences in diagnostic practice, although, admittedly, the therapist’s personality might have some influence as well. It is of course true that the particular concept of schizophrenia that one works with has some bearing on the matter as well; the concepts of Bleuler and Swiss psychiatry are looser than those of Kraepelin and German psychiatry. Nevertheless, as even followers of the same schoo! often disagree about the diagnosis in individual cases, doctrinal influences are probably not all that important. It is remarkable that it is rare for a diagnostician to be able to indicate exactly how he artives at a diagnosis of schizophrenia. He might point out widely accepted symptoms such as schizophrenic thought disorder, the loss of awareness of own activity, ideas of influence, ‘intrapsychic ataxia’,’ affective stiffness,* the impossibility of empathy, the absence of a vital contact with the external world,? autism, the schizophrenic smile or even the delusions of persecution or world destruction."° His opponent, however, distinguishes such phenomena in various other illnesses as well, c.g. in confusional manias, schizoid psychopathies, atypical involutional states, degenerative psychoses and various uncertain cases which definitely do not warrant a label of schizophrenia. Alternatively, the opponent might claim that ‘splitness’ does not exist at all, he might find the smile quite appropriate, he might be able to empathize with this patient without difficulty, or he might think of autism as a ubiquitous phenomenon. The conclusion will often de that the proponent has sensed a E, Stransky, ‘Zur Kenntniss gewisser erworbener Blodsinnsformen’, Neurologisches Zentralblati, sei (1903), 1-149, ‘Thie author describes the ‘intrapeychic atixia’ ae "cine StOrung. des koordinierten Zusammenspiees zwischen Thymopsyche und Noopsyche" (disturbance of the smooth interplay between, Thymopsyche and Noopryche). He represents a srend in German poychiatric research which conceptualized the paychical sa series of layers’ superpesed on each ther. This epresents an elaboration ofthe Aristotelian theory which described the prychical at consisting of three layers, namely Trieb (drive) Seele (soul) and Geis: (spirit). The Thymopsyche fepresents in Strasskey’s model the emctional (deeper) Iyer, the Noopsyche, the layer of the ‘ideation. Incongraity between idestions and emotions causes tke picture of intropsychic ataxia, * E. Bleuler, Lehrbuch der Psychiatrie (Berlin: Julias Springer, 1916), 283; ‘Veberhaupt ist eines. der sichesten Zeichen der Krankheit det Defekt det affective Modulationsfihigceit, die affektive Steifeket, The defec of affeet-modulation, the affective siffinss, ivone of the most certain signs ofthe illness), O'E. Minkowski, Le Temps ode, deules phinominoloiques et pochopathologigues (Neuchatel: Delachaux ct Niestlé, 1968), 59. Otherwise termed synchronisme vécu; la faculié d’avancer hanson ae eens ambowtChe possi of moving tovard he fren Raron ‘with theeavironment). © For instance, O. Fenichel, The Prycho-analytic Theory of Neuroses (London: Routledge, Kegan & Paul, 1982), 417; ‘the fantasy frequeatly met with in the early stages of schizophrenia — thi the world is coming to an end 336 H.C. ROME specific schizophrenia or praecoxfeeling during the interview of this patient - he has noticed that this patient’s mental state has a specific schizophrenic colour. It will become clear that this is decisive for him. The opponent would have diagnosed schizophrenia with all these symptoms and signs but he has not sensed the praecoxfeeling. Here we have arrived at today’s question: ‘What is the praecoxfeeling?’ I feel that this term is preferable to ‘schizophrenic colouration’, as it implies that a feeling, induced in the clinician, is the final and most important guideline. AAs it plays such an important role in diagnosis, it deserves some further analysis and in this study I will try to work out on which basis I diagnose schizophrenia. I should first point out that the above-mentioned symptoms in themselves almost never justify a diagnosis of schizophrenia; they are useful to illustrate the diagnosis, but for me they lose all their pathognomonic value if what I consider as essential is lacking. Tf one tries to put one’s finger on what it is that gives the afore-mentioned symptoms a schizophrenic colouration, then the conclusion must be that it is something that cannot be classified in the usual way but that it is comprehended in all the categories of the conventional mental state examination. The phenomenon is most clearly interwoven with the affective disturbances, the anomalies of thought and with the psychomotor symptoms. This undcfinable attribute that surrounds all the observed symptoms induces the praecoxfeeling. Can we define it more accurately? Even after a very brief mental state examination it becomes clear to the psychiatrist that his empathy is lacking. It is not only the patient’s affect that cannot be empathized with; it is impossible to establish contact with his personality as a whole. One becomes acutely aware that this is caused by ‘something’ in the patient; the ‘directedness? toward other people and the environment is disturbed. Somewhat pathetically one could say: ‘the schizophrenic is outside the human community’. This lack of intercourse with people is not merely an affective disturbance; something is affected that determines the relationship between people, and this cannot be exhaustively described by the conventional mental state examination, which after all deals with patients who are observed in isolation. One of the most fundamental attributes of man as a social creature is his inclination to establish contact with others, and this is not an act of will but a purely instinctual drive. This urge remains below the level of awareness as long as it can be satisfied; it reaches consciousness if its goals cannot be met. (There is a human instinct to avoid contact as well, but I will not discuss it heres it exerts a polarizing influence which calls for separate investigation.) The weakening of this instinct which I will call the rapprochement-instinct, is probably the fundamental phenomenon in schizophrenia and 1 know of no other condition in which this instinct is so thoroughly affected. As interpersonal relations are not one-sided, the investigator examining a sufferer from schizophrenia notices something out of the order within himself; he cannot find the patient. The one-sidedness of the attempts to establish a