Initial Psychiatric Assessment of a Deaf Somali Refugee

The psychiatric diagnostic profile of the DHH population differs from that of the hearing population. Anxiety was found to be more prevalent in DHH populations in eight out of 10 studies with comparator hearing groups (6), and significant differences were found in rates of attention-deficit hyperactivity disorder, substance use disorders, intellectual or developmental disorders, and trauma exposures between DHH and hearing populations (7, 8).


A likely cause of these differences, especially for anxiety disorders, is ubiquitous communication barriers, affecting the etiology, natural history, diagnosis, and treatment of anxiety. Many people with hearing loss are surrounded by hearing families and communities, and thus have limited communication with others. Those who communicate entirely through sign language are often met with discrimination and exclusion. These factors can lead to constant worries of missing key details, mental fatigue, and feelings of social isolation, predisposing the person affected to feelings of anxiety and depression.


Cultural competency is loosely defined as the “recognition of the diversity between and within cultures, capacity for cultural self-assessment, and willingness to adapt personal behaviors and practices” (9). As mentioned above, the capital-D Deaf designation carries along with it the notion of Deaf culture, or the shared experience of those who use sign language and embrace a shared heritage, history, and tradition (10). Also important to note are the intersecting identities, including ethnicity and refugee status, that lent further complexity to the assessment of this patient.


A few well-known cases of children, such as the Lobo Wolf Girl and Genie, have been documented as growing up without access to spoken language during the critical periods of language acquisition (11, 12). In populations with hearing loss, such cases are exceedingly more common. About 90% of deaf children are born to hearing parents (13) and have minimal to no exposure to others who are Deaf. In many cases, the family fails to obtain fluency in sign language or to enable sufficient access to signed or spoken languages. Often, the later communication of such people with language deprivation includes combinations of established signs, local variants, home signs, foreign signs, and gestures. Furthermore, deficiencies in vocabulary, temporal descriptors, and causal or hypothetical relationships may yield significant difficulty in formulating a coherent psychiatric narrative (14).


The major adjustment to the Mental Status Examination (MSE) of patients who sign is in the traditional “Speech” section. Box 1 details the MSE of the patient discussed in this report. Rate, rhythm, spontaneity, and latency are recorded as for spoken language, but volume and tone in sign language must be described differently as amplitude and inflection, respectively. The “volume,” or amplitude, is reflected in the size of the signs, whereas “tone,” or inflection, is understood by the range of emphasis put on certain signs. Although psychiatrists generally look for nonverbal cues such as facial expressions, such expressions are a linguistic feature of ASL. Therefore, in the modified “Sign” section for a patient using ASL, clinicians should also comment on the patient’s expressions.


Examples of interesting MSE findings (not pertinent for this case report) are clanging in mania and responding to internal stimuli (RTIS) in psychosis. ASL does not have the potential to rhyme, so signed clanging would instead present via the use of the same “handshape” (15) across unrelated signs. In psychosis, RTIS may be observed in the subtle shift of “sign space” where a patient may physically shift the angle of his or her body or arms toward the perceived source of internal stimuli.


In psychiatric assessment, the “how” is as important as the “what” among patients’ communication. However, medical interpreters, although well trained in terminology, may organize a patient’s language while attempting to convey meaningful information to the provider and thereby inadvertently mask psychopathology (16). This practice may apply across signed and spoken languages, especially given the minimal resources, let alone requirements, for interpreters to be specially trained in mental health concepts (for an example of such a training, see the Mental Health Interpreter Training project at www.MHIT.org). In interpreting for a patient with mania, for example, interpreters may not recognize signed “clanging” as such and simply interpret each word the patient is signing without mentioning the irrational sameness of the handshapes. Of note, language dysfluency is quite likely to be interpreted as disorganized thought and therefore to be labeled as “psychosis not otherwise specified” (17).