Discussing Rümke’s “Praecox Feeling” from the clinician’s experience of schizophrenic contact Discutindo o “sentimento precoce” de Rümke do ponto de vista da experiência do clinico no contato esquizofrênico

“Praecox Feeling” (“Praecox Gefühl”) was a notion introduced by the Dutch psychiatrist H.C. Rümke as an attempt to emphasize schizophrenic gestalt as a key feature for diagnosis. Our purpose is to decrypt Rümke’s work and to offer a critique based on a case study. From a phenomenological framework, we attempt to show the relevance and the limits of this concept in order to enlighten contemporary nosographic issues. Rümke suggested that symptoms themselves are not reliable for a rigorous diagnosis of schizophrenia. He proposed the term of Praecox Feeling to describe the bizarreness experimented by the clinician from the first minutes of the encounter with a person with schizophrenia. This notion refers to Karl Jaspers “radical incomprehensibility” of mental disorder. Our point is to take seriously this incomprehensibility to think a second person approach to diagnosis. To explore this track, we will focus our interest on the clinician subjective experience of schizophrenic encounter. In this regard, we will not think bizarreness as polarized on the patient’s side, but rather as an inbetween event. Since then psychopathologic comprehension call for an epistemology of human contact and minimal-social space. Schizophrenic encounter needs then to be revisited in a more dynamic and embodied way.


Introduction
A rebound of scientific interest has appeared during the last decades about a nosographic way of thinking psychiatric diagnosis. However, the clinical core of schizophrenia remains an enigma. A blind spot around which gravitates psychopathology since its beginning. Each theoretical breakthrough has always revealed new mysteries.
"Praecox Feeling" was a notion introduced by the Dutch psychiatrist Henricus Cornelius Rümke as an attempt to emphasize schizophrenic gestalt as a key feature for diagnosis. The purpose of this article is to decrypt Rümke's work and to offer a critique based on case study.
From a phenomenological framework, we attempt to show the relevance and the limits of this concept in order to enlighten contemporary nosographic issues. Rümke suggested that symptoms themselves are not reliable for a rigorous diagnosis of schizophrenia. He proposed the term of Praecox Feeling to describe the bizarreness experimented by the clinician from the first minutes of the encounter with a person with schizophrenia. This is not an objective clinical sign, but rather a pre-semiologic recognition of symptom's schizophrenic quality.
Qualified as "indefinable" since it is non-verbal and then inaccessible to a third person perspective (Vargas, 2013).
The aim of this study is to share a clinical account regarding the notion of Praecox feeling. That is to say the feeling of bizarreness experienced by the clinician during a meeting with a person suffering from schizophrenia and which could allow some very skilled clinician to make the diagnosis from the first sight. Praecox feeling covers notions of "diagnostic by penetration" from Eugene Minkowski (1927), "atmospheric diagnosis" from Hubertus Tellenbach (1968), or "diagnostic by Intuition" from Ludwig Binswanger (2016) and Jakob Wyrsch (1949). For Rümke, Praecox feeling allows to denote a specific unease, experienced in the encounter. Rümke claimed that Praecox feeling was an attempt to capture the clinical core of schizophrenia. It means a certain gestalt of first rank symptoms (Rümke, 1990) which signs their schizophrenic nature. This experienced unease is difficult to qualify in linguistic format (Rümke, 1958). However, in an article of 1942, Rümke suggested that Praecox feeling reflects an impossibility to establish a contact with the patient's personality as a whole because of some "lack of exchange of affect" in the patient and, consequently some "impossibility for empathy". A kind of closeness to the investigator. This idea was almost as old as the notion of schizophrenia itself, and Eugen Bleuler claimed that we had no "affective Psicopatologia Fenomenológica Contemporânea, 2017;6(2):112-123 contact" with a schizophrenic person 1 by this statement he was referring to the radical unshareability of schizophrenic experience. But if schizophrenia is a radical otherness for the clinician, how can it be described in a first person perspective? How can there be an access, albeit precarious and fleeting, allowing the clinician to develop a genuine phenomenological description? Without any inter-affective contact, there is no basis for an intuitive empathic understanding. If it must be acknowledged, with Minkowski the central role of "schizophrenic autism" and the "loss of vital contact with reality", we cannot deny that people with schizophrenia affect us, touch us, and often disturb us. This paradox appears in all its complexity with the phenomenon of Praecox Feeling, which aggregates all at once the radical otherness of the schizophrenic experience and the evidence of its pathological manifestation (Bleuler, 1950).

Methodology
To unfold this paradox, we wanted to submit the account of a clinical encounter from the perspective of the clinician. Very few recent studies had been made to explore the reliability and validity of Praecox Feeling as a diagnostic tool in clinical practice (Wiggins, 1987;Grube, 2006;Ungvari, 2010). These researches had intended to compare Praecox Feeling to operationalized diagnostic system as ICD-10 and DSM-IV, showing very incoherent experimental results. Both authors emphasized the very necessity of phenomenological studies on conceptual issues and qualitative methodology. There is no recent study decrypting the clinician's subjective experience from a first person perspective.
This case study is presented here with a non-conventional methodology in that it is a tentative of a "perspectivist" approach to psychopathology. That is an account of the encounter situated on the clinician side, as the only accessible perspective. This methodology appeared necessary to be able to elaborate a knowing about the other from a second person perspective.

Moreover, if psychiatric and phenomenological literature have insisted on that Praecox
Feeling is only accessible to very skilled and experimented clinician, this present clinical narrative was conduct by a young psychiatric trainee. Psicopatologia Fenomenológica Contemporânea, 2017;6(2):112-123

Clinical encounter
Maurice, 35 years old; has been suffering from schizophrenia for a dozen years. This time he came to the hospital because he wasn't able to get out of his apartment. Everything in the outer world is problematic, complex and requires careful consideration. Actually everything changed for Maurice since he fell ill. Now nothing is simple. Maurice feels concerned by so many things, with details of his daily life. As though there were no hierarchy between the signs over which to rely to act and which to ignore as mere elements of the environment. "It's hellish! I think too much, he explains, before it was so simple, I knew what to do or say. Now nothing is obvious." When we met for the first time, he was mistrustful, secret and anxious. He didn't look into the eyes, took time to answer in a mysterious way.
Later, he has been able to confide he had the feeling I could read his mind. He felt violated, naked and alone. It took time to get used to each other. In the ward he was discreet, invisible almost. He left without notice and returned at odd hours in the night to the nurses' utter despair. From then onward, we allowed Maurice to go back and forth between his apartment and the hospital. He was departing with some astrological predictability when the evening sun was waning and when the parrots in the hospital park burst into song. Sometimes he came back in the middle of the night, explaining that a car honked at the very moment when he had the idea of returning, this coincidence certainly meaning it was time to go. Maurice's suffering is about not being well anywhere. As though he were empowered by a secret force along the path of invisible stars nestled in the banality of things. He can't live in any place without being attracted elsewhere. During a month, Maurice was there in a game of presenceabsence that didn't make any sense for us. It was just a co-presence without any real intersubjective contact.
Actually, our relationship changed when Maurice told me about his "crazy" project.
He had seen at the hospital entrance, on the ground floor, a bar, with a counter, tables, everything. Except there was no one to enjoy this and no one to run the place. So, we worked on the project, we thought together about the creation of a café inside the hospital where it would be possible to host patients and families more warmly. This café should be handled by him. Of course, we had to negotiate with the administration, set up an association, etc.
Anyway, some great work of imagination and audacity. This project was like a piece of world, crafted together. An imaginary sub-universe between us. The question wasn't to know whether or not it was possible. Whether or not it was reasonable or clinical. It was a play area. Psicopatologia Fenomenológica Contemporânea, 2017;6(2):112-123 "There is nothing more serious than playing," Winnicott (1971) wrote. In this regard, sociologist Alfred Schütz (1976) states that it is possible to stand a sincere social relationship with someone if and only if you give one's experience the nature of an authentic reality. So that the inter-subjective experience, the sharing of something common is only possible with "faith in the veracity of the other." The phenomenological approach in care in general and in psychiatry in particular therefore opens onto an ethic of encounter. Which necessitates a deconstruction of the commonly accepted hierarchy between usual reality and delusional reality. Having a sincere relationship means sharing a sphere of reality in which an exchange is possible on equal terms. It's necessary to be able to build up some chimerical world, probably this does not often happen; but make this inter-subjective event possible is a horizon that we should aim to in psychotherapeutic setting.
In this sense, inter-subjectivity doesn't merely deal with psychological exchange between two isolated Egos but with the field of a possible communication. In other words, this raises the question of the existence of a common world of experience which could be shared. Therefore, empathetic feeling doesn't cover all the meanings of the phenomenological notion of inter-subjectivity. Danish philosopher Dan Zahavi (2001) argues that empathic situation where I attempt to thematically grasp the experience of others is the exception rather than the rule. My everyday relationship to the world is a relation to a shared world, where everything refers to others. Self-world relatedness is always mediated by the reference to other persons regardless of whether or not they are actually present. It is a world alwaysalready used by the others. That's why Heidegger (1962) said Dasein was always being-with.
In fact, it's when the usual daily experience of reality is broken that we refer to empathy to thematically grasp the emotions or the experiences of others. For example, in a care situation, when the other person experiences an unshareable pain, imminence of death, delusion, etc.

Metaphorization and mutual confidence in a shared world
Slowly Maurice and I have started to build mutual confidence. The issue of this exploration is to make some very intimate experiences intersubjectively shareable. The authors therefore emphasize the use of metaphor to describe pre-linguistic pathological self-experiences. So that an experience, especially if it is prereflexive, is brought to be linguistically thematised by the subject in a poetic language type.
The role of the evaluator is to accompany the patient in this process of symbolization. This exercise calls for creativity and confidence between the patient and the evaluator. So that shareability of pathological self-experience must be crafted together.