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Prelingually profoundly deaf schizophrenicpatients
who
hear voices:
l-
a
phenomenological analysis
du Feu
M,
McKenna
PJ.
Prelingually profoundly
dcal
schimphrenic patientswho hear voices:
a
phenomenological analysis.Acta
Psychiatr
Scand
1990:99:
453-459.
1
Munk5gaard
1900
Objective:
'The
aims
of
the
study
were
to
examine claims
that
profoundlydeaf schizophrenic patients report auditory hallucinations, and to evaluateproposed explanations that
such
patients
arc really describing othcrsymptoms,
or
that
the
phenomenon
is
restricted
to
those
who
had
heard
and
understood language prior
to
becoming deaf.
Method:
A
total
of
17
schizophreniclschizoaffective
patients
with
onset
of
profound deafness prior to
the
age
of
2
years underwent structuredpsychiatric interview.
Results:
Ten patients
(SO%)
gave
accounts
of
verbal auditory
hallucinations
with description
of
content. These
did
not
appear
to
be
attributable to otherpsychotic experiences
and
showed typical characteristics
of
schizophrenic
hallucinations.
Thc
symptom was
prescnt
in
six
patients
who
had
been deaf
from birth
or
early infancy.
Conclusion:
These findings suggest
that
auditory hallucinations are
a
common phenomenon
in
profoundly prelingually
deaf
schizophrenicpatients, which cannot
be
accounted for
by
the above explanations.
Introduction
Schizophrenia occurs in prelingually profoundlydeaf patients with probably the same frequency asin the hearing population
(l),
and when it does itssymptoms are broadly comparablc to those inhearing individuals
(24).
This, it might be thought,would
be
with the exception
of
auditory hallucina-tions, as it is difficult to imagine how such asymptom could
be
experienced by patients whohave either never heard speech or who
lost
theirhearing before they acquired the ability to com-prehend spoken language. Surprisingly, however,claims that profoundly deaf patients report hearingvoices have been made repeatedly from the latterpart
of
the last century to the present day
(5-10).
Various explanations have been put forward forthis counter-intuitive phenomenon. Perhaps themost popular has been that when deaf schizo-phrenic patients state that they are hearing voices,they are really describing other, non-auditoryexperiences
(3).
Thus close questioning of appar-ently auditorily hallucinated patients has revealedthat some
of
them were experiencing visualhallucinations
of
signing and finger spelling
(8),
M.
du
Feu',
P.
J.
McKenna'
'Queen Elizabeth Psychiatric Hospital, Edgbaston.Birmingham and 'Fulbourn Hospital, Cambridge UKKey words deafness,schirophrpnia,auditory hallucinations
P
J
McKenna. Fulbourn Hospital, Addenbrooke's
NHS
Trust, Cambridge, UKAccepted for publication January
4,
1999
hallucinations
of
vibration
(9),
delusions about realsensations
of
pressure or vibration
(6),
or bizarredelusions involving air currents, etc.
(8,
9).
Avariant
of
this proposal, suggested by Altshuler
(ii),
has been that the experience is a wish-fulfillingdelusion related to the desire to be able to hear.A certain amount
of
dissatisfaction with suchexplanations has nevertheless been expressed.
Somc
authors
(8,
9),
while accepting that theirpatients' exact subjective experiences were difficultto determine, described patients who referredexplicitly to noises or talking, or finger-spelledthe word 'heard'. Similarly, Altshuler
(6)
statedthat, while minute scrutiny could suggest thatvibration rather than sound was being perceived,or that words were felt instead
of
being heard, thisdid not answer the question
of
why deaf patientstypically insisted that they were hearing something.He also observed that explanations invokingfulfilment
of
the wish to hear failed to accountfor the fact that voices appeared to
be
reportedabout equally frequently by deaf and hearingschizophrenic patients.
453
%
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Daagohbs
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yae
Auditory hallucinations in deaf schizophrenic patients
Another explanation has been proposed thatonly patients who have lost their hearing after theyhave heard and understood speech experienceauditory hallucinations when
they
become schizo-phrenic. Evans and Elliott (2) examined
13
deafpatients with a clinical diagnosis of schizophrenia,of whom 10 individuals were prelingually deaf and
3
individuals became deaf after acquiring language,or had an unknown age of onset. Three subjectswere found to experience auditory hallucinations,all
of
whom, according
to
the authors, ‘at somepoint in their lives had experienced sound to somedegree
.’
The aim of the present study was
to
provide aphenomenologically rigorous examination of thequestion of what prclingually profoundly deafpatients are really experiencing when they statethat they hear voices.
It
was also considered ofinterest to determine whether such patients cxpcri-ence other auditory or quasi-auditory phenomena,such as elementary hallucinations, thought broad-casting and thought echo.
Material and methods
Pat
en
s
The sample was drawn from patients under the care
of
oneof the authors
(M.
du
F.),
who is theconsultant psychiatrist to a unit for dcaf people,and
so
has wide experience
of
the presentations
of
psychiatric illness
in
deaf individuals. All admis-sions over a 28-month period who had been given aclinical diagnosis of schizophrenia or possibleschizophrenia were assessed while they wereacutely ill. An additional sample of out-patientswho were known to experience ongoing psychoticsymptoms was also interviewed.Patients were considered to be profoundly deaf ifthey had no usable hearing for their own or others’speech and for normal environmental sounds, evenwith the use of hearing aids.
If
audiometry wasavailable, a
loss
of
at least 80 decibels was requircd.Background information concerning degree
of
deafness, age of onset, cause, etc., was obtainedfrom case-notes and, where possible, enquirieswere made of relatives.
Procedure
The patients were interviewed using the ninthedition of the Present State Examination (PSE)
(11).
This covers a wide range of psychiatricsymptoms and is particularly suited to obtainingphenomenologically rigorous descriptions of psy-chotic symptoms. Following normal practice,
in
most cases only the psychotic sections
of
theschedule (sections 12-15) were administered.However, in some patients (e.g. where the diag-nosis of psychosis was uncertain or whcre anaffective component was suspected) the wholeinterview was given. Objective ratings of beha-viour, affect and speech (sections 18-20) were notmade due to difficulties
in
interpreting theseparameters in deaf subjects. Only patients whocould communicate freely in sign-language
(BSL)
were interviewed.The
PSE
was administered by onc of the authors(P.J.M.) who is experienced in its use, with theother author
(M.
du F.) putting the questions insign-language. Typically,
M.
du F. translated thepatients’ signed replies to questions to P.J.M. asthey answered, and the PSE ratings were filled
in
on
this ‘verbatim’ basis. This procedure allowedquestioning
to
proceed smoothly and accurately inmost cases, and enabled possible auditory phenom-ena to be explored in detail.
If
it became clear thatcommunication was difficult (e.g. because thepatient was failing understand the questions), orquestioning became laborious, the examination wasdiscontinued.After the interviews, diagnoses were assignedaccording to the Research Diagnostic Criteria
(12).
Whenever possible the diagnoses were made on thebasis
of
symptoms other than apparent auditoryhallucinations (or other auditory phenomena).
Results
Over the period of study 21 patients were inter-viewed,
of
whom
it
was possible to carry out
PSE
examinations on
17
subjects. All of the patientsfulfilled
the
requirements listed above for profounddeafness. Only two of the patients (cases 8 and
16)
had developed significant speech; this was with‘oral method’ teaching. The age
of
onset ofdeafness ranged from birth to some time before 2years. All of the patients met RDC criteria forprobable or definite schizophrenia or schizoaffec-
tive
psychosis on the basis
of
symptoms other thanauditory hallucinations. Diagnostic and other datafor the 17 patients are listed in Table
1.
Also
shown in Table
1
are the PSE ratings forhallucinations and other auditory phenomena.
It
can be seen that
10
of the
17
patients
(59%)
gaveaccounts of current verbal auditory hallucinationswith description
of
content. The voices wereexperienced in the second and/or third person.Both true hallucinations and pseudohallucinationswere described (in the PSE, pseudohallucinationsmerely refer to voices heard inside the head),sometimes both by the same patient.
In
addition,two patients described hearing voices from their
455
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