Grube Michael
Klink fur Psychiatrie und Psychotherapie, Stadtische Kliniken Frankfurt a. M., Akademisches Lehrkrankenhaus der Universitat Frankfurt, Frankfurt a.M., Germany.
Psychopathology. 2006;39(5):209-17. doi: 10.1159/000093921. Epub 2006 Jun 14.
The early identification of schizophrenia is important in establishing an adequate therapeutic intervention, especially in emergency situations. Intuitive reasoning is often necessary because a standardized classification according to ICD-10 or DSM-IV criteria is not suitable in these complex, and often changing, settings. The process of recognizing the specific schizophrenic structure in an intuitive way by an experienced psychiatrist was named 'praecox feeling' by the Dutch psychiatrist Rümke in 1941.
To evaluate the diagnostic quality of this kind of intuitive clinical approach we investigated 67 previously unknown patients. All patients displayed acute psychotic symptoms like paranoid delusions and hallucinations belonging to the schizophrenic spectrum. The first interview by an experienced psychiatrist included only the present state psychopathology. Data referring to the course of the illness or medication or family history of schizophrenia were explored later by other independent staff members who were blind to the aim of the investigation. The intensity of the 'praecox feeling' was rated in four degrees: not present--mild--moderate--high. At the end of the inpatient period a standardized diagnostic classification according to ICD-10 and DSM-IV classification was carried out by independent raters.
Compared to the standardized diagnostic classification the precision of the intuitive reasoning was remarkably high with a sensitivity of about 0.85, a specificity of about 0.80, a positive predictive power of about 0.90, and a negative predictive power of about 0.65 depending on the standardized system used. Cognitive impairment, affective disturbances, disturbed self-perception, and reduced communication skills all correlated with intensity of 'praecox feeling'. The single variable 'affective disturbances' had the highest impact on the intensity of 'praecox feeling' in an ordinal regression analysis. Furthermore a high intensity of 'praecox feeling' strongly correlated with a hereditary predisposition to schizophrenia. Neither the severity of the mental illness nor extrapyramidal side effects of the medication correlated with the intensity of 'praecox feeling'.
Our work can possibly help in contributing to reflection on our diagnostic practices and help to make the various factors involved in establishing diagnoses apparent.
精神分裂症的早期识别对于确立适当的治疗干预措施至关重要，尤其是在紧急情况下。直观推理往往是必要的，因为根据国际疾病分类第10版（ICD - 10）或精神疾病诊断与统计手册第4版（DSM - IV）标准进行的标准化分类并不适用于这些复杂且常常变化的情况。1941年，荷兰精神病学家吕姆克将经验丰富的精神科医生以直观方式识别特定精神分裂症结构的过程命名为“早发性感觉”。
为评估这种直观临床方法的诊断质量，我们对67名此前未知的患者进行了调查。所有患者均表现出急性精神病性症状，如属于精神分裂症谱系的偏执妄想和幻觉。经验丰富的精神科医生进行的首次访谈仅涵盖当前状态的精神病理学内容。关于疾病病程、用药情况或精神分裂症家族史的数据，随后由对调查目的不知情的其他独立工作人员进行探究。“早发性感觉”的强度分为四个等级：不存在——轻度——中度——高度。在住院期结束时，由独立评估人员根据ICD - 10和DSM - IV分类进行标准化诊断分类。
与标准化诊断分类相比，直观推理的精确度显著较高，根据所使用的标准化系统，其敏感性约为0.85，特异性约为0.80，阳性预测值约为0.90，阴性预测值约为0.65。认知障碍、情感障碍、自我感知紊乱和沟通技能下降均与“早发性感觉”的强度相关。在有序回归分析中，单一变量“情感障碍”对“早发性感觉”的强度影响最大。此外，“早发性感觉”的高强度与精神分裂症的遗传易感性密切相关。精神疾病的严重程度和药物的锥体外系副作用均与“早发性感觉”的强度无关。
我们的工作可能有助于促进对我们诊断实践的反思，并有助于使诊断过程中涉及的各种因素更加明显。
