Issues in acute psychosis of an illiterate hearing impaired with minimal speech output: A psychiatrist perspective.

Sir,

Assessment and management of mental disorder among sensory impaired is challenging as there is no clear guideline. Most physicians and psychiatrists are not trained to provide competent care in such patients. This report highlights the issues and challenges that a clinician may encounter in patient with profound hearing loss and speech impairment.

World Health Organization has reported that 360 million people live in this world with hard of hearing.[1] Prevalence of psychotic disorder among hearing impaired did not differ from hearing population.[2] Differences do exist in conceptualizing abnormal behavior between hearing and the hearing impaired. Manifestation of psychopathology differs due to variation of nonverbal language skills. Most physicians are not trained to provide competent care in patients with profound hearing loss and speech impairment.[3] This report highlights the issues and challenges that a clinician may encounter in such patient. Index patient Mr. M, a 20-year-old unmarried illiterate male was unable to talk or hear since birth. His symptoms started abruptly and persisted for last 3 days, which were characterized by crying, confining to his room, restlessness, decreased sleep and appetite and poor personal hygiene. He was mostly preoccupied, did not interact with others and needed considerable effort to attract his attention. Patient was brought to the emergency room by family members. An interpreter to whom the patient agreed to interact, assisted throughout inappropriate setting of the interview. It took few hours to obtain the consent following which evaluation was done. On observation, his hygiene was poor. He seemed to be restless, often making gestures, at times preoccupied &inattentive, fearful, sad & crying and at times agitated. With the help of the interpreter, it took 3 days when rapport was well established, and the patient started revealing his symptoms. His main concern was hearing of voices continuously. Eight known males who died earlier were individually calling him He could not reveal the characteristics of voice or the content. However he only could make out that all were different voices. He would try to go out of his room when voices were loud. He was convinced that he was going to die because his father had the same complaints and died after jumping into a well. He was also concerned about his family because he was the only breadwinner of his family. There was no history of psychiatric illness in the past. His father committed suicide 8 months back after developing similar complaint. He was hearing impaired and close to the patient. Patient was born out of a consanguineous marriage (mother married to maternal uncle). Except for speech and hearing, other milestones were reported normal. He did not have any formal education or training of sign language. He used to communicate with gesture. He would work daily at home or any work given by family members and was able to do simple calculations related to money. He has good relation with family members and neighbors. He had many friends and was known for his hard working and honesty among them. Physical examination and investigation revealed patient having congenital profound hearing loss and minimal speech output. No other abnormality could be elicited. A psychiatric diagnosis of Acute and Transient Psychotic Disorder was made.[4]

On admission, he was given diazepam 10 mg slow intravenous stat. To control agitation, he received diazepam 10 mg slow intravenous thrice on separate days. After diagnosis had been made, he was prescribed to take olanzapine 10 mg tablets at night. The patient improved within 7 days. Pychoeducation and supportive psychotherapy were given with the help of the interpreter. It was very difficult to explain many aspects of the illness and treatment due to the communication barrier and his difficulty in understanding the concepts. He was discharged with tablet olanzapine 10 mg/day as he did not reveal any significant side effects. He was referred to the speech and hearing department for detailed evaluation and management. He was followed up weekly for 1st month, followed by twice a month. There was no relapse of symptoms. This case highlights many issues of the hearing impaired with minimal speech especially related to ethics, assessment, diagnosis and management. Usually most issues arise due to nonverbal communication, inability to use sign language by examiners and patient and absence of clear guidelines. There is no universally accepted method of mental status examination in an illiterate hearing impaired with minimal speech. Index patient communicated with only gestures as he did not attend school teaching sign language. Expression of ideas and experience in gesture can be misinterpreted as psychopathology.[5] This was partly overcome through interpreter. Providing appropriate interpreter, obtaining informed consent and establishing rapport was challenging. It was difficult to empathize, give positive regard and eliminate culturally based fears due to cultural difference.

This patient had a diagnostic issue. Initial differential diagnoses were severe depressive episode and acute and transient psychotic disorder until experience of hearing voices was established. Current diagnostic guidelines are based on data of hearing population. Chance of under diagnosis of psychosis is more in uneducated hearing impaired with minimal speech because it is often difficult to elicit psychotic symptoms, delusional perception, illogicality, unusual explanations or bizarreness, hallucinations, loss of reality, etc., Auditory hallucinations in hearing impaired have been a controversial phenomenon of psychosis. Hearing impaired with schizophrenia often experience voices with some auditory feature[6] but inadequate deconstruction of the concept of “voices.”[7]

Another issue was the impact of life event and unusual experience.[8] eight months back, the patient's father had similar complaint of hearing voices and committed suicide. The event helped to develop delusional beliefs in him that he was going to die and this lead him to severe distress.[9] Trauma may adversely affect hearing impaired due to possible difficulties in social understanding and misattribution of the causes. Some other issues were the difficulty in providing appropriate care of multidisciplinary approach compatible to the culture of hearing impaired, informed pharmacotherapy, eliciting different types of psychotic symptoms, empathizing and offering other effective psychological intervention, explaining common side effects likely to experience etc., At present, guidelines on assessment and management of hearing impaired psychiatric patients with psychotic disorders is scarce in the scientific literature.[10] Development of culturally and linguistically appropriate assessment tools such as structured clinical interviews, symptom inventories, screening measures and tests of cognition is urgently needed. Similarly, appropriately modified evidence based psychotherapy and multidisciplinary approach is also needed. Finally, training provider in assessing the hearing impaired patient population should become a standard part of the diversity-related curriculum of physician training programs.