Deaf and self-signing

CASE Self Signing
Mrs. H, a 47-year-old, deaf, African American woman, is brought into the emergency room because she is becoming increasingly withdrawn and is signing to herself. She was hospitalized more than 10 years ago after de­veloping psychotic symptoms and received a diagnosis of psychotic disorder, not otherwise specified. She was treated with olanzapine, 10 mg/d, and valproic acid, 1,000 mg/d, but she has not seen a psychiatrist or taken any psy­chotropics in 8 years. Upon admission to the inpatient psychiatric unit, Mrs. H reports, through an American Sign Language (ASL) interpreter, that she has had “problems with her parents” and with “being fair” and that she is 18 months pregnant. Urine pregnancy test is negative. Mrs. H also reports that her mother is pregnant. She indicates that it is difficult for her to describe what she is try­ing to say and that it is difficult to be deaf.

She endorses “very strong” racing thoughts, which she first states have been present for 15 years, then reports it has been 20 months. She endorses high-energy levels, feeling like there is “work to do,” and poor sleep. However, when asked, she indicates that she sleeps for 15 hours a day.

Which is critical when conducting a psychiatric assessment for a deaf patient?

a) rely only on the ASL interpreter
b) inquire about the patient’s communica­tion preferences
c) use written language to communicate instead of speech
d) use a family member as interpreter

The authors’ observations
Mental health assessment of a deaf a patient involves a unique set of challenges and requires a specialized skill set for mental health practitioners—a skill set that is not routinely covered in psychiatric training programs.

a We use the term “deaf” to describe patients who have severe hearing loss. Other terms, such as “hearing impaired,” might be considered pejorative in the Deaf community. The term “Deaf” (capitalized) refers to Deaf culture and community, which deaf patients may or may not identify with.

Deafness history
It is important to assess the cause of deafness,^1,2 if known, and its age of onset (Table 1). A person is considered to be pre­lingually deaf if hearing loss was diagnosed before age 3.² Clinicians should establish the patient’s communication preferences (use of assistive devices or interpreters or preference for lip reading), home commu­nication dynamic,² and language fluency level.^1-3 Ask the patient if she attended a specialized school for the deaf and, if so, if there was an emphasis on oral communica­tion or signing.²

HISTORY Conflicting reports
Mrs. H reports that she has been deaf since age 9, and that she learned sign language in India, where she became the “star king.” Mrs. H states that she then moved to the United States where she went to a school for the deaf. When asked if her family is able to communicate with her in sign language, she nods and indicates that they speak to her in “African and Indian.”

Mrs. H’s husband, who is hearing, says that Mrs. H is congenitally deaf, and was raised in the Midwestern United States where she at­tended a specialized school for the deaf. Mr. H and his 2 adult sons are hearing but commu­nicate with Mrs. H in basic ASL. He states that Mrs. H sometimes uses signs that he and his sons cannot interpret. In addition to increased self-preoccupation and self-signing, Mrs. H has become more impulsive.

What are limitations of the mental status examination when evaluating a deaf patient?

a) facial expressions have a specific linguis­tic function in ASL
b) there is no differentiation in the mental status exam of deaf patients from that of hearing patients
c) the Mini-Mental State Examination (MMSE) is a validated tool to assess cogni­tion in deaf patients
d) the clinician should not rely on the in­terpreter to assist with the mental status examination

The authors’ observation
Performing a mental status examination of a deaf patient without recognizing some of the challenges inherent to this task can lead to misleading findings. For example, sign­ing and gesturing can give the clinician an impression of psychomotor agitation.² What appears to be socially withdrawn behavior might be a reaction to the patient’s inability to communicate with others.^2,3 Social skills may be affected by language deprivation, if present.³ In ASL, facial expressions have specific linguistic functions in addition to representing emotions,² and can affect the meaning of the sign used. An exaggerated or intense facial expression with the sign “quiet,” for example, usually means “very quiet.”⁴ In assessing cognition, the MMSE is not available in ASL and has not been vali­dated in deaf patients.⁵ Also, deaf people have reduced access to information, and a lack of knowledge does not necessarily cor­relate with low IQ.²