A
clinical and psychological study of
echo-reactions
Srengel Ed, Vienna MD, Edin LR
Department of
Clinical Research, Crichton Royal,
Dumfries
The automatic repetition of words heard
(echolalia) and actions (echopraxia) has long
been known to occur in certain psychotic states
in cases of aphasia and in low-grade mental
deficiency. Echographia was establihed as a
sub-type of echopraxia (Pick, 1924). The
similarity of the pathological echo-reactions
with phenomena occurring normally in childhood
during the early period of speech development
was pointed out by Wyllie (1894) and Pick
(1902), who studied them in aphasia. The most
recent study dealing with echo-reactions is that
of D. E. Schneider (1938), who described the
syndrome echolalia, echopraxia, grasping and
sucking. Most previous writers investigated
echo-reactions either from the neurological or
psychiatric point of view and not enough
attention has been paid to the comparative
aspect and to the question of a common
underlying mechanism. In this study an attempt
has been made to investigate that problem.
Echo-reactions have been observed chiefly in
the following conditions: (1) Aphasia of the
transcortical type and advanced dementia
resulting in a similar speech disorder. (2)
Low-grade mental deficiency with incomplete
development of speech. (3) Chronic epilepsy. (4)
States of clouded consciousness of various
origins. (5) Catatonic states. (6) Early period
of speech development in childhood. (7) States
of fatigue and lack of attention in the
normal.
Echo-reactions in Aphasia.
In certain cases of aphasia (transcortical
aphasia of the classical scheme) echolalia is a
marked feature. Although the anatomical and
physiological concepts underlying that term are
now obsolete, the existence of the aphasic
syndrome described by that name has been
established beyond doubt. It was studied most
thoroughly by Kurt Goldstein (1917). Spontaneous
speech as well as understanding of spoken
language are, as a rule, considerably reduced in
cases with marked echolalia. Arnaud (1887) was
the first to distinguish two types of echolalia
which may be observed in the same patient; the
one consisting of automatic repetition of words
which were not understood; the other in which
apparently automatic repetition helped the
patient to understanding the words spoken to
him. Pick (1902) followed up Arnaud's
observations in studying the changes which
automatic echolalia underwen t in the course of
restoration of speech. Compulsive parrot-like
repetition changes into "mitigated echolalia",
i.e. questioning repetition of the words
heard.
That type of echoing may become modified by
introduction of the first person singular into
the sentence repeated by the patient, and may be
followed by an intelligent response to the
question or order. With complete restoration of
the understanding of spoken language, the
tendency to repetition disappears. Clinical
observation of suitable cases confirms Pick's
description of the various phases of echolalia.
In cases in which the restoration of
understanding is incomplete, the echo-reaction
becomes stabilized in one or the other phase.
The transition from automatic echolalia into
almost deliberate repetition argues against the
assumption that the automatic echo-reactions are
fundamentally different from the others.
In 1935 the present writer reported on a
hitherto unknown phenomenon in cases of
"transcortical aphasia" which seemed to throw
new light on the nature of the echo-reactions.
It was first observed in a 60-year-old woman
with a right-sided hemiplegia whose spontaneous
speech was reduced to the recurrent utterance
"te-te." Understanding of spoken language was
almost completely lost. Automatic speech, such
as counting and singing, could be elicited by
appropriate stimulation. The patient could not
repeat spoken language intelligently on order,
but she showed marked echolalia: The latter
occurred only in the conversational situation,
i.e. when the patient was addressed. If the
examiner turned his back to her and spoke to
himself or to somebody else, however loudly and
slowly, she did not echo. She did so, however,
when her eyes were covered so that she could not
see whether or not she was addressed. The same
behaviour was observed in other aphasic patients
with echolalia. It proves that echolalia is not
indiscriminate automatic repetition of words
heard, but depends on a specific setting, i.e.
the conversational situation.
Completion phenomenon.
If the examiner spoke to the patient
sentences of simple contents slowly without
completing them, the patient responded, as a
rule, not with echolalia, but with completion of
the sentence. Sometimes she would echo the last
word spoken by the examiner and then
spontaneously complete a sentence.
Specimen responses: (" How did you sleep
last . . . ? ") "Night's or "Last night." (" You
are a good . . .") "Woman." (" Shake ." "
Hands."
When there was a variety of possibilities
open to her for completion her responses varied
according to her mood and to the situation, e.g.
(" Life is is) " Hard" or " Good" or "
Difficult." (" The weather is . . Fine to-day"
or "Bad to-day." (" What did you have for . .
.") "Supper" or "Lunch" or " Breakfast,"
according to the time of day. Grammatical
mistakes made on purpose by the examiner in the
sentence to be completed, tended to inhibit the
completion response. The patient also reacted to
changes in the meaning of sentences, e.g. the
sentence "Life is . . was invariably completed
by her according to her mood, but she was
perplexed and did not react at first when the
sentence was worded "Mr. Life is ." However,
after a moment's hesitation, she continued "A
man."
The completion response was always a
spontaneous reaction and appeared to be as
automatic and compulsive as echolalia. The
patient showed marked signs of satisfaction when
she had succeeded in completing a sentence which
she had never been requested to complete. Even
if she had, her lack of understanding of spoken
language would have prevented her from
appreciating such an instruction.
If the examiner completed a sentence himself
the patient started accompanying him from the
moment she would have been able to take
over.
The completion phenomenon has never been
found missing by the author in cases of aphasia
with echolalia since it was first observed. With
the restoration of understanding the completion
phenomenon undergoes changes similar to those of
echolalia. Automatic completion is superseded by
a probing, sometimes questioning, continuation
of the sentence, not unlike the reaction which
one would expect of a healthy subject who, owing
to lack of attention, does not fully appreciate
what he is expected to say. With progressive
improvement of speech the spontaneous completion
response becomes more difficult to elicit and
gradually disappears.
The completion phenomenon in cases of lost
or greatly impaired receptive speech is of
interest for a theory of understanding of spoken
language. It suggests that the patient, although
unable to understand, has some knowledge of what
the other person is saying and intending to say.
That knowledge is not identical with what is
called understanding of spoken language; but the
capacity of producing, within limits, what the
interlocutor is going to say appears to be a
precursor of full comprehension.
Compulsive repetition could in those cases
be replaced by compulsive completion of schemata
of thoughts and sentences, given suitable
experimental conditions. The interchangeability
of, and the overlapping between, echolalia and
completion phenomenon suggested that the
psychological mechanism underlying both
reactions was the same. Even without
consideration of the completion phenomenon, the
old conception of echolalia as reflex repetition
of words heard appeared unsatisfactory, as the
repetition was, as a rule, confined to the
conversational situation, which implies a
specific relation to the person uttering the
word. (Exceptions to that rule will be discussed
later.) The compulsive completion of sentences
and thoughts into which echolalia could be
changed did not fit into the theory that the
latter was simply an expression of a primitive
tendency to automatic imitation. In completing
sentences of another person with whom the
patient has established rapport in the
conversational situation, he is making that
person's intentions his own and is thus able to
follow them to their conclusion, provided the
thoughts expressed and their formulation are
within the range of his knowledge and speaking
abilities. The mechanism underlying the tendency
to adopt another person's intentions and to act
like him was called "identification" (Freud,
1922). The present writer (1935) proposed that
the completion phenomenon and echolalia were
instances of identification on a primitive
level. That concept, unlike the previous ones,
took into account the condition under which
echolalia occurred, as well as the completion
phenomena. Schneider has later (1938) adopted
the same interpretation of the
echo-reactions.
The completion phenomenon described here
requires also to be considered the light of the
Gestalt psychology, to be understood more fully.
By completing sentences spontaneously the
patient showed the tendency to change a "bad
Gestalt," i.e. an incomplete structure, into a
"good" one, i.e. a complete structure.
Completion phenomena, especially in visual and
auditory perception, played an important part in
the foundation and development of Gestalt
psychology. Reference to that aspect will be
made later in this article.
Echo-reactions in Low-grade Mental
Deficiency with Incomplete Speech
Development.
The study of the speech of the idiot seems
of little value for the understanding of aphasic
phenomena if one understands aphasia to be the
complete or partial loss of the normal faculty
of speech. If, however, we regard aphasia as the
lack of symbolic formulation and expression
(Head, 1918) and take into account the
regressive character of aphasic reactions, as
recognized first by Hughlings Jackson, the
rudimentary language of the low-grade mental
defective becomes a matter of great interest in
the study of acquired speech disorders. There
can be no doubt about the relationship between
the language of the idiot and certain early
phases in the speech of the child. The former
can be regarded as speech arrested at a certain
phase of its development.
The supposition that there is an intimate
relationship between aphasia and the rudimentary
speech of the mental defective is borne out by
the study of echo-reactions. The various stages
of echoing as seen in aphasics can be
demonstrated in low-grade mental deficiency. The
completion phenomenon corresponding to the type
of echolalia present could also be elicited in
those cases, and both were used by the patient
as a means of learning to speak, in a similar
way as they are used in the early stages of
childish speech.
The following cases are examples from a
considerable number of IoW-grade mental
defectives with echo-reactions whom the writer
has observed in the course of his studies.
CASE 1.-Seventeen-year-old male low-grade
mental defective with major epileptic fits.
The patient showed echolalia, echopraxia,
and echographia. He had athetoid movements in
the upper extremities and spontaneous movements
of the neck, reminiscent of torsion spasm. There
were no pyramidal signs. The patient showed the
sucking reflex, but no grasping. Echolalia
occurred only in the conversational situation,
and echopraxia and echographia only when
personal rapport had been established.
Understanding of spoken language was very
limited. Simple orders were carried out and
questions which the patient could understand
were answered, as a rule, without echoing.
Correct responses to more difficult questions or
orders which he could still understand were
often preceded by echolalia. Otherwise echolalia
was the only reaction to spoken language.
Usually the word most stressed in the sentence
was repeated. Foreign words were echoed with
great accuracy. The completion phenomenon could
easily be elicited. The patient spontaneously
completed the sentences correctly, provided they
were within the range of his speech, which was.
very limited. Completion was, as a rule,
preceded by echoing of the part of the
senteñèe spoken to him. He showed
the same tendency when serial numbers, letters
of the alphabet and parts of nursery rhymes were
spoken to him. It was cottparatively easy to
teach the patient sentences which he learned to
complete spontaneously.
Extract from examination records.-(" What is
your name? ") "Name?
Peter H."-(" How are you? ") Are you. Very
well, thank you."-(" Anypain?") "No pain."-("
Where do you live? ") "Live."-(" Crichton
Royal") "Royal."-(" How old are you? ") "Old?
ten."-(" How old are you ?
"Are you."-(" What is the time? ") "What is
the time? Twenty minutes past eight"
(incorrect).-(" Are you a good boy? ") "Good
boy, that's a good boy."-C' Write your name ")
"Write your name." (Pt. takes the pencil and
writes his name in capital letters.)-" Shut your
eyes ") Does so without echoing. .-(" All right
") Opens them.-(" Where is your ear? ") "Ear?"
Points to his left ear.-(" Where is your nose?
") Points to his nose.-(" Where is your left
hand? ") "Hand?" Raises both hands. He is unable
to distinguish between right and
left.-Subsequent orders to get up, to sit down,
to put out his tongue, etc., are carried out
promptly without echoing.-(" I, 2 ") " I, 2, 3,
4, 5, 6."-(" a, b ") "a, b, c, d, e,
r."-(Bonjour ") "Bonjour."-(" Guten Tag ")
"Tag."
Completion phenomenon.-(" How ...")" How are
you? Very well, thank you"; or, on another
occasion, "How old are you ? "-(" What is
your
Name? Peter H."-(" Are you a ...?Are a good
boy?"
The patient completed sentences in a foreign
language after they had been spoken to him four
to five times. He also learned to count in a
foreign language. When a story was slowly read
out to him he repeated the words emphasized and
accompanied the reading by echoing. The patient
was shown familiar objects with the question
"What is this? "or" What do you call this? "
When he could name the object correctly (e.g.
handkerchief, spectacles, matches, tie, pencil,
keys, cat) he did so without echoing; but he
echoed the question when he could not name a
pound note shown to him.
When the examiner spoke to himself, for
instance looking at his watch and remarking on
the time, the patient did not echo although he
seemed to listen attentively.
Echopraxia.-Patient reacted with echopraxia
to such actions only which he could carry out
fully himself in the particular situation. He
did not echo manipulations with objects which
were not at his disposal. His behaviour proved
that, in this case at least, echopraxia was not
an indiscriminate automatic repetition of
actions seen. The patient was echopractic only
if the action he observed fitted into his "total
situation."
Specimen responses.-The examiner
successively coughed, whistled, got up from the
chair, sat down, sneezed, put his tongue out,
stamped his foot three times, tapped on the
table four times. The patient, without being
requested to do so, repeated those actions
promptly and correctly. When the examiner took
out his watch and wound it, or took his
spectacles off, or opened his purse or cigarette
case, the patient, though following those
actions attentively, did not even attempt to
repeat them. However, when a coin was put on the
table in front of the patient and thrown into
the air, he promptly took the coin and repeated
the action. When the examiner pinched patient's
right hand he immediately pinched his own right
hand. He did exactly the same when the examiner
pinched his own right hand and he repeated other
actions on his own body which the examiner
performed on himself., When imitating the
patient never trepassed beyond his own body. He
did not reciprocate actions carried out against
himself, but imitated or, completed them on
himself.
When the examiner pulled his tie out the
patient, who on that occasion was not wearing a
tie, did nothing; on the following day, when he
was wearing a tie, he repeated the action
immediately.
Completion phenomenon.-When the examiner
only initiated an action familiar to the patient
without carrying it out, the patient, on his
part, completed it.
Echographia.-The patient could, to order,
write his name in capital letters and some
letters of the alphabet. He could read only a
few letters contained in his Christian name.
When a pencil and a piece of paper were lying in
front of him and the examiner wrote single
letters or made simple drawings, the patient
spontaneously copied them.
CASE 2.-Low-grade female menial defective,
aged 26.
The patient had major epileptic fits in
childhood. Her speech had not developed beyond
the ability to form short sentences in telegram
style and to understand simple questions or
orders. Familiar objects were named correctly.
There was marked echolalia and the completion
phenomenon could be elicited.
Specimen responses.-(" You are a good girl
") "Good girl."-(" You are a
Good girl."-(" Get up ") Patient does it
without echoing.---The patient had her hair cut
on the previous day. (" Who has cut your . .
"Hair? Hairdresser."-(" What is your name? ")
"Mary."-(" How are you? ") "Very well."-(" Open
your ...")" Mouth."-(" You are a silly ...")"
Girl."-(" What date is to-day? ") Is to-day?
"-(" How long have you been in hospital? ")
"Hospital?"
When the examiner turned his back to the
patient and spoke in a similar manner as before,
no echo-reactions ensued. When, however, her
eyes were covered so that she could not see that
she was addressed, she echoed promptly and
completed sentences. The patient sang nursery
rhymes when the beginning of a rhyme was sung to
her.
There was marked echopraxia and a tendency
to complete familiar actions initiated by the
examiner. She followed the doctor's actions in
the ward with great interest and tried to
imitate them, even when they had not just been
carried out; for instance, she would take the
reflex hammer from a tray and test her patellar
and ankle jerks, or take a needle and stroke her
sole. On two occasions she took a spatula and a
torch, opened her mouth and carried out the
movements that she had seen the doctor carry out
in the examination of the pharynx. She also
imitated activities of the nurses. The selective
nature of echopraxia was very marked in this
case.
CASE 3.-Low-grade mental defective, aged 47,
with infantile hemiplegia.
The patient showed mitigated echolalia and
the corresponding phase of the completion
phenomenon. Often her echoreactions were similar
to those of a normal subject who is inattentive.
The patient spoke little spontaneously. Her
sentences were of the telegram style.
Understanding of spoken language, although
limited, was better than in the cases described
above. Naming of simple objects was intact. She
could read and write short words.
Specimen responses.-(" When were you born?
") When I was born? 1889."-(" What sort of
weather are we having to-day? ") "Weather? It is
raining, isn't it? "-(" Have you got any
children? ") "Children? I am not married."-("
Why do you repeat everything I say? ") "Beg
pardon. I did not listen."-(" I have a new suit
") "Oh, you have a new suit, doctor."-(" I have
a brown wallet ") "Brown wallet."-(" Have you
stolen a lot? ") "Stolen? I am a good
girl."
In this patient whose understanding of
spoken language was fairly good, the completion
phenomenon could only occasionally be elicited
and if it occurred, it was of the probing,
questioning type. For instance, (" Open your . .
. ") "Mouth?" and does it.
The similarity between the mitigated
echoreactions of this patient and those of a
normal subject in a state of inattention was
very obvious. It was noteworthy that the patient
herself explained the tendency to repetition as
due to lack of attention. She appeared to repeat
in order to understand better. If, however, her
attention was stimulated by the provoking nature
of what was said to her, mitigated echolalia was
either followed by an intelligent response or
she answered without echoing.
Other cases observed showed reactions
similar to those described above. In some of
them, especially in those with very rudimentary
speech, the sucking reflex was present. A
considerable proportion of low-grade mental
defectives with echoreactions were either
subject to major epileptic fits or had had such
fits in childhood.
Echo-reactions in Chronic
Epileptics.
It has been pointed out above that a
considerable proportion of mental defectives who
showed echo-reactions were epileptics. Echoing
is sometime.s observed in cases of chronic
epilepsy who are not mentally defective. It
occurs in the state of clouded consciousness
following major fits and also in epileptic
twilight states. Occasionally it can be found as
a habitual reacti in advanced epileptic dementia
when mental activities in general, and speec in
particular, are slowed down. Provided the
disturbance of consciousness at the time of the
examination was not too severe, the completion
phenomenon, too, could be observed in
epileptics.
It seems that echolalia in epileptics was
seen more frequently by the old psychiatrists
than now-a-days, when the frequency of fits is
reduced by anti epileptic treatment. Tuke (1876)
spoke of the "echo-sign in the epileptics" and
described it as a typical post-convulsive
phenomenon in chronic cases.
Echo-reactions in States of Clouded
Consciousness.
In states of clouding of consciousness due
to brain lesions or intoxications echolalia
often occurs. It has been described in cases of
coal gas, barbiturate and alcohol poisoning, and
in various forms of delirium and coma. The
occurrence of echolalia during the restoration
of consciousness after a major epileptic fit has
been mentioned above. If return of consciousness
is gradual the transition from automatic to
mitigated echolalia can sometimes be observed.
Echolalia is, of course, possible only if the
disturbance of consciousness is not too deep to
prevent the perception of outside stimuli. The
completion phenomenon could occasionally be
elicited in states of clouded
consciousness.
Schneider (1938) has noted the occurrence of
echolalia in the hypoglycaemic coma induced
therapeutically. Mayer-Gross and the present
writer (1945) have pointed out that it is apt to
emerge in a phase of the awakening from
hypoglycaemic coma in which paraphasia and a
tendency to clang associations and iterations
were also present. Echolalia was more frequent
in cases of relatively quick recovery of
consciousness from insulin coma. Sometimes the
patient tended to echo words or even noises not
directed to him. It is clear that in that
condition the patient is unable to differentiate
between words directed to him and to others. He
behaves like the aphasic patients whose eyes are
closed. The occurrence of echolalia in insulin
coma has no relationship to the clinical type of
the psychosis. It is noteworthy that the stage
of consciousness in which echolalia sometimes
makes its appearance in the awakening from
insulin coma is preceded by a phase in which the
sucking reflex can often be observed. Those two
phases may overlap. The co-existence of sucking
and, echoing is obviously not incidental, as
both are primitive oral reactions to, outside
stimuli.
Echo-reactions in Catatonics.
The echo-reactions in acute catatonics
impress the observer as even more automatic than
in other conditions. Mitigated echolalia, in
which the patient repeats apparently with a
degree of understanding, is uncommon in those
patients. Only on two occasions has the writer
observed the completiofl phenomenon in acute
catatonic states. The rarity of the latter and
of mitigated echolalia in acute catatonies is
obviously due to the fact that they implY a
degree of mental cooperation which those
patients do not as a rule provide
Echo-reactions can sometimes be observed in
advanced cases of chronic catatonia. They may be
present over many years, but they cannot be
elicited with the same regularity as in aphasics
and mental defectives. They are subject to the
same variability as cataleptic phenomena and
schizophrenic mannerisms. The writer has
observed two cases in which echo-reactions came
permanent symptoms in deteriorated catatonics
many years after the onset of the psychosis.
Both patients, prior to their illness, had been
intellectually backward, though not grossly
defective. This is of interest in view of the
occurrence of echo-reactions in low-grade mental
defectives. The following is a short report on
the case observed recently.
CASE 5.-Male chronic catatonic, aged
45.
Has been in hospital since he was 20. He
started talking at the age of three and was
always regarded as somewhat dull and backward.
His progress at school was below average, but he
could express himself very well and learned to
read and write without much difficulty. He left
school at the age of 14 and went to work on a
farm. His employer described him as a good
worker, though slow in the uptake. No
intelligence tests were carried out, but the
history was suggestive of highgrade mental
deficiency. At the age of 16 he became odd, lost
interest in his work and isolated himself. His
condition grew gradually worse, his habits
became faulty and he had impulsive outbursts. On
his admission to hospital in 1922 he presented
the picture of a deteriorated catatonic. He did
not speak spontaneously. When questioned he
replied very slowly and in monosyllables. He had
periods of inaccessibility during which he was
mute and negativistic. A few years later he
became very noisy and was destructive at times.
In 1937 echolalia was first noted and has
remained very marked since. He also shows
echopraxia. Catalepsy with flexibilitas cerea
are present.
The echo-reactions in this patient are very
similar to those seen in low-grade mental
defectives with incomplete development of
speech, but they are less -constant. He would
often, with or without echoing, answer a simple
question correctly or comply with a request to
which, on other occasions, he would respond only
with echolalia. When addressed by the doctor he
would often add "Sir" to the words echoed, thus
giving his reaction a conversational character.
He did not echo when not addressed. The
completion response could be elicited as a rule,
but sometimes it was mi,ssing when he failed to
establish rapport with the examiner. When
echoing or completing sentences he sometimes
made additions referring to --the doctor or
himself.
Specimen responses.-(" it is cold to-day ")
It is cold to-day. Sir."-(" How long have you
been here? ") "Been here ? "-The following day
he replied to the same question" A good long
time."-(" Do you like it here? ") "Like it here
?" -(" Do you hear voices?Yes."-(" What do they
say? ") "Say? "(" What is your ...?Name?" The
following day he responded to the same words
with "Birthday? "-(" How do you like being . . .
? ")
In here? '-(" Write your name! ") "Write
your name."-(" Write your Write your name, you
fool! "-(" It is rather . . . ! ") " Rather cold
to-day, I think."-(" You are a silly ...")"
Silly fool."-(" i ") " I, 2, 3."-(" a ") "a, b,
c, d."-The patient sings the National Anthem and
a nursery rhyme without being requested to do so
when they are begun by the examiner. When
addressed in a foreign language he always
echoes, sometimes adding "Sir."
The patient imitates simple actions carried
out by the examiner, such as getting up, sitting
down, raising an arm, tapping on the table, etc.
However, when asked to write his name or words
on dictation he only scribbles about. Otherwise
his echopraxiá is of a similar type to
that of the first case of mental deficiency
described above.
It is interesting that in this patient, who
in all probability was a high-grade mental
defective, the schizophrenic deterioration
resulted in a regression to a level of speech
observed in low-grade mental defectives. Without
the aid the history the patient could easily be
mistaken for such a case.
Echo-reactions during the Early Stages of
Speech Development.
Echolalia during the early stages of speech
development is well known to the psychologist. A
tendency to imitation of gestures, inarticulate
sounds and the inflection of a voice can be
observed at as early an age as eight months.
Articulate echolalia rarely occurs before the
age of two. Echolaiia is very marked in some
children, while it may be completely lacking in
others. Froschels (1918) suggested that the
emergence of echolalia in childhood depended
upon a discrepancy between a strong impulse to
speak and a poor ability to understand. Children
in whom the impulse to talk is weak in the early
stage of speech development, as well as those
whose understanding is fairly advanced,: are not
likely to show marked echolalia.
In echoing words and actions the child
identifies itself with persons of its
environment, and especially with those to whom
it is attached emotionally. Piaget (1932) has
pointed out that the element of play is of great
importance in the imitiative behaviour of the
child. He differentiates between egocentric and
socialized functions in the language of the
child and does not agree with Janet and Baldwin,
who regard the childish imitation as a confusion
between the "I" and "Not I." According to
Piaget, the game of imitating, although it seems
to apply a social attitude, is essentially
ego-centric. He believes that the copied
movements of words have nothing in them to
interest the child and that there is no
adaptation to anyone else. "The child does not
know that it is imitating, but plays his game as
if it were his own creation. That is why
children up to six, when they have had something
explained to them, and are asked to do it
immediately afterwards, invariably imagine that
they have discovered by themselves what in
reality they are only repeating from a model. In
such cases imitation is completely unconscious."
Piaget's observations prove the enormous power
of the tendency to identification in childhood.
According to Freud, identification is for the
greater part an unconscious process. As it
implies a relationship to another person it is a
fundamentally social mechanism. The game of
repeating words heard is one of the means in
which the child identifies itself with its
models.
The echo-reactions of the child are not as
compulsive and automatic as in aphasia or
thental deficiency. They depend a great deal on
the child's mood and on its willingness for
imitation. They also show a considerable
selectivity. The same applies to the completion
phenomenon which can be easily elicited in young
children. Like the adult aphasic or mental
defective, they show a tendency to carry on with
sequences initiated by another person and they
avail themselves of it for the purpose of
learning speech patterns. The readiness of the
child to imitate speech and to complete
sentences is one of the most important means of
teaching a child to speak. With the progress of
spontaneous speech and understanding of spoken
language, reactions corresponding to mitigated
echolalia and its counterpart of the
completiàn phenomenon: make their
appearance. Those reactions can also be observed
long after speech fully developed whenever a
difficulty in understanding arises. Such
difflulties may be due to lack of comprehension
or of attention. It can be seen om those
observations that echo-reactions in mental
defectives have much common with those of the
normal child.
Echo-reactions of the Normal Adult in
States of Fatigue and Lack of
Attention.
In conditions of drowsiness and fatigue when
attention to external stimuli is low or
diverted, and comprehension of spoken language
suffers as a result, the normal subject
sometimes shows echolalia, usually of the
mitigated type. In those states he may even
occasionally respond to words not directed to
him. Sometimes such reactions can be elicited by
speaking to a person who is in a state of
awakening from natural sleep. Another instance
is the, usually mitigated, echolalia which may
occur when a person whose full attention and
interest is taken up by his own thoughts or by
some other pre-occupation, is addressed
unexpectedly. He either would not respond at all
or he only half listens, in which case he may
respond with mitigated echolalia; for instance,
the question "What is the time? "may not elicit
any response; or it may be echoed automatically
without being answered, or it may provoke
mitigated echolalia (" What the time is? ")
followed by an appropriate reply. In persons who
are in a state of reduced alertness to outward
stimuli, characterized by the layman as
"absentmindedness," such reactions are not
uncommon and have become a topic of popular
jokes.
Conditions in which the normal subject
encounters difficulties in understanding what is
spoken to him may result in the emergence of
echo-reactions, especially when, at the same
time, attention is faulty. One of those
conditions is the stage of learning a foreign
language when understanding is still incomplete.
In that stage the student is in a situation not
unlike to that of a patient suffering from
auditory aphasia, and he will often find himself
repeating automatically, although not
necessarily aloud, a question or a request
directed to him, before responding
intelligently. Mitigated echolalia, often almost
deliberate, is not uncommon in that situation.
In those echo-reactions of a person grappling
with a foreign language, the mechanism of
identification with the interlocutor for the
purpose of better understanding of spoken
language is obvious. There is also a tendency to
verbalization and completion of sentences
offered incomplete, as if to make sure of full
comprehension. Those reactions lack the
compulsive character of the corresponding
reactions in pathological cases. With
progressing command of the foreign language they
cease to occur, but they are more liable to
reappear in states of fatigue and inattention
than in the mother tongue. It is of interest in
this connection that cases of aphasia in
polyglots have been observed which showed
echolalia in the last-learned language only
(Bateman, 1870; Pick, 1916; Schneider,1938).
DISCUSSION.
The conditions under which echo-reactions
are observed have the following features in
common; an impulse to speak on the one hand, and
incomplete development or impairment of
expressive as well as perceptive speech on the
other. That constellation can be demonstrated in
the various states listed above. The conditions
under which echopraxia can be observed are
similar. There is an urge to act and an
impairment or incomplete development of
spontaneous activity. Probably the emergence of
echo-reactions depends on a certain quantitative
relationship between urge and impairment.
Some notes on the psychology of
echo-reactions.-Echo-reactions in their various
forms have above been interpreted as expressions
of a primitive tendency towards identification
with other persons. They are fundamentally
social reactions and, in their automatic form,
rudiments of such. The observations in children
justify the assumption that when we first learn
to use speech as means of social intercourse we
identify ourselves with those who are speaking
to us. In that stage of speech development, and
under certain abnormal conditions, repetition of
spoken words often precedes intelligent
response. The patient with the automatic form of
echolalia does not get beyond the stage of
repetition, i.e. identification with the
interlocutor. Automatic echolalia can, be
described as a rudimentary response to being
addressed in the conversational situation.
Repetition preceding the response to spoken
words can be observed in normal conversation
only when the speech mechanisms are not
functioning fully. It may also occur in a normal
subject when, owing to difficulty of
comprehension, an immediate intelligent response
is impossible. An example of such a reaction is
the semi-automatic or even automatic repetition
of questions put to a candidate at an oral
examination.
Echopraxia has its normal corollary in the
unconscious imitation by a normal subject of
another person's movements, especially when he
is watching with intense interest and is
instinctively putting himself in the other's
place.
The question may be asked whether
echo-reactions are not sufficiently explained as
imitation phenomena, and whether anything is
gained by introducing the concept of
identification. Echo-reactions are, of course,
instances of imitation on a primitive level and
may be regarded as expressions of an instinct of
imitation postulated by some writers. But by
calling them imitation phenomena we do not go
beyond the purely descriptive and almost
tautological. In characterizing them as
instances of identification on a primitive level
we are introducing an interpretative term; we
are referring to the underlying mechanism which
implies a certain emotional relationship to the
model and thus accounts for the selective nature
of the echo-reactions as far as the situation
and the choice of the model are concerned. The
fact that echoreactions often occur only
relative to certain persons has also been
illustrated in Schneider's case material. It is
well to remember that identification is the
mechanism underlying the phenomena of
suggestibility.
The term identification refers to the social
aspect of the echoreactions. That interpretation
has to be supplemented by an examination of the
phenomena from the point of view of Gestalt
psychology. The great value of that approach for
the formal understanding of the completion
phenomenon is evident. Gestalt psychology also
throws light on the dynamics of echoreactions.
Lewin's (1927) and Koffka's (1932) studies of
behaviour are of particular interest in the
analysis of echolaiia and the associated
completion phenomenon. A person who is addressed
becomes, with the interlocutor, rt of a
"behavioural field." The words spoken to him
call forth tensions enianding discharge.
Normally those tensions are released by an
appropriate jponse. If this is impossible, owing
to impairment of comprehension or
other faculties, the forces tending to
"close the gap" in the total situation ay lead
to the emergence of at least a rudimentary
response. Lewin called hose tendencies "quasi
needs," in analogy to the biological needs of
the rganism. Those "quasi needs" are created by
events or objects which have the character of an
appeal. In this terminology, words directed to a
person produce the "quasi need " for an
appropriate response. A pattern of a sentence
offered incomplete calls for completion. The
beginning of a sequence of numerals, of the
alphabet, of a song, appeal for continuation.
Echolalia can be regarded as an attempt at
"closing the gap " in the conversational
situation. Viewed from that angle echolalia,
too, is a completion phenomenon.
The primitive level of mental activities on
which automatisms take place reveals forces at
work in the behavioural field which otherwise
can be demonstrated only under carefully
selected experimental conditions. However, it
would not be possible to interpret fully the
specific features of the echo-reactions on those
lines without introducing the concept of
identification which throws light on the nature
of those forces.
Echo-reactions in schizophrenia, especially
in catatonic states have been observed in
association with signs of automatic obedience
and other automatisms. They have been
interpreted as due to the inhibition of
intentions in the presence of a surplus of
impulses, and as illustrations of the impotence
of genuine activity (Mayer-Gross, 1928). They
often co-exist with signs of negativism. The
recognition of the fundamentally social
mechanism of identification underlying the
echo-reactions throws some light on their
occurrence in schizophrenic states. They are
expressions of an impulse to maintain social
contact, however rudimentary, in a condition
which is otherwise characterized by withdrawal
from social intercourse. The co-existence of
features of those contradictory attitudes is
typical of the schizophrenic ambivalence which,
in the sphere of psycho-motor activities, is
most marked in the catatonic states. The form
and nature of the echo-reactions are
characteristic of a regression to a very early
stage of behaviour. What has been said of the
echo-reactions in early infancy by Janet and
Baldwin, i.e. that they belong to a stage of
development in which there still exists a
confusion between the "I" and "Not I" applies
equally to the schizophrenic regression -in
which the boundaries of the ego have broken
down.
The description of echo-reactions as
instances of automatic obedience given in
current text-books is correct only in a
physiological sense, in that the patient, under
certain conditions, obeys a stimulus.
Psychologically the response is not one of
obedience but a mixture of refusal to respond
appropriately and a rudiment of co-operation,
whereby the former attitude dominates the
situation. The behaviour of a child who has
learned to speak but would react to words spoken
to him with parrot-like repetition would be
regarded as one of obstinacy and spite rather
than of obedience.
Physiologically, echo-reactions have been
classified by Wylie (1894) as reflex phenomena.
Pick (1902) regarded echolalia as a conditioned
reflex without, however, analysing the
conditions under which it arose from th
psychological point of view. In his view
echolalia is a sign of the reemergence of an
infantile accoustico-motor speech reflex which
is an important mechanism in the normal process
of learning to speak. He regarded the echolalia
of the aphasics as a release phenomenon due to
loss of certain inhibiting functions of the left
temporal lobe.
Automatic echo-reactions are primitive
reponses illustrative of the over excitability
of the organism in conditions of disintegration
of nervous functions described by Goldstein
(1942). The patients are "tied to the
stimulus."
Echo phenomena are examples of automatisms
in which the transition from the automatic to
the almost voluntary and purposeful reactions
can be observed. They illustrate Hughlings
Jackson's contention that there is no antithesis
between the automatic and the voluntary, and
that there are only degrees from the "most
automatic " to the "least automatic " which is
the voluntary. The progress of evolution,
according to Jackson, is from the former towards
the latter, while dissolution progresses in the
opposite direction. Either development can be
demonstrated in the various phases of echolalia.
Jackson's thesis of the fundamental unity
between automatic and voluntary forms of
behaviour bears out the necessity for the
psychological study of both groups of
phenomena.
Jackson pointed out the relationship of
certain forms of automatisms to emotional states
and illustrated this on many cases of aphasia.
The fact that echolalia occurs only in the
conversational situation when personal rapport
has been established is of interest in this
connection, as personal rapport implies a degree
of emotional relationship to the interlocutor.
The observation that many patients echo only
when addressed by certain persons points even
more strongly to the part which the emotional
factor plays in the conditioning of
echo-reactions.
Echolalia has sometimes been confused with
palilalia. Both phenomena have occasionally been
observed in the same case. It is doubtful
whether they are closely akin, and whether
Brissaud's (1899) description of palilalia as
autoecholalia refers to more than a superficial
similarlity based on the tendency to repetition
which they have in common. Critchley (1927),
comparing the two phenomena, emphasized the
absence of aphasia in cases with palilalia. He
has pointed out that the latter is a disorder of
speaking rather than of speech and is to be
regarded as a purely motor mechanism similar to
the festination of gait. Psychologically,
palilali lacks the social element inherent in
echolalia. However, conditions leading to
palilalia have something in common with those in
which echolalia occurs, first of all the slowing
up of mental activities, and sometimes clouding
of consciousness. Both phenomena have been
observed to co-exist in cases of
post-encephalitic Parkinsonism (Burger and
Mayer-Gross, 1928; Critchley, 1927). They have
in common arl underlying tendency to repetition,
but they belong to different levels of mental
activities, that of echolalia being much lower
than that of palilalia. This is also borne out
by the not infrequent co-existence of
echo-reactions with such primitive reflexes as
sucking and grasping (Schneider's
syndrome).
Pathology.-There is no unanimity
about the localization of lesions responsible
for the emergence of automatic echo-reactions in
pathological cases.
Goldstein (1917) regarded frontal lobe
lesions as important, while Pick (1916)
expressed the view that echolalia was the result
of a loss of inhibition of speech impulses due
to destruction of the left temporal lobe. Kleist
(1934) maintained that lesions of the basal
ganglia were responsible for echo-reactions.
However, in view of their primitive nature a
localized lesion alone, even if every extensive,
is unlikely to produce them. Bastian's (1890)
statement that echolalia can only be found with
general impairment of cerebral functions is
borne out by clinical as well as pathological
observations. The present writer has only in one
case of marked echolalia carried out a post
mortem examination. It was the aphasic patient
described above in whom the completion
phenomenon was first observed. A thrombosis of
the left middle cerebral artery was found, which
had resulted in destruction of the whole speech
area. The softening extended into the putamen.
Cases such as this suggest that what was left of
speech could hardly have originated in the
dominating hemisphere. Hughlings Jackson
expressed the opinion that automatic speech
originated in the right hemisphere. According to
him the left hemisphere is the " creative," the
right the "automatic." Whether a lesion of the
basal ganglia is necessary for echolalia to
arise can only be decided by a series of
anatomical investigations of suitable
cases.
SUMMARY.
The various conditions in which
echo-reactions occur have been reviewed.
Echo-reactions do not consist of indiscriminate
repetition, but depend on personal rapport. The
selectivity of echo-reactions, with regard to
both the person imitated and the actions
repeated, has been demonstrated. The
fundamentally social nature of echo-reactions
has been pointed out. The tendency of the
patients with echo-symptoms to complete
automatically sentences and actions initiated by
the persons with whom they have established
contact has been described. Those completion
phenomena are an alternative to, or superimposed
on, echo-reactions. The psychological mechanism
underlying echo-reactions and the associated
completion phenomena is that of identification
on a primitive level. The various phases which
echolalia and the associated completion
phenomenon undergoes in the course of the
evolution and re-evolution of speech have been
demonstrated. A new interpretation of
echo-reactions in schizophrenia has been
advanced. They are to be understood, from the
psychological point of view, as the result of an
impulse to maintain social contact co-existing
with the opposing tendency to extreme autism. An
unusual case of chronic catatonia has been
reported in which echo-reactions existed over
many years. This patient, who had been a
highgrade mental defective, had in the course of
his psychosis regressed to a level of speech
corresponding to that of low-grade mental
deficiency. Echo-reactions in infancy and those
occurring under certain conditions in normal
adults have been discussed. The conditions in
which echolalia occurs have been found to have
in common an urge to speak or act, a tendency to
repetition and an incomplete development of
impairment of expressive as well as perceptive
speech. The conditions for echopraxia are
similar but concern motor activity The
echo-reactions have been analysed from the point
of view of Gestalt psychology, which throws
light on their formal as well as dynamic
significance. The pathology and some aspects of
the physiology of echo-reactions has been
discussed. The part played by the emotional
element in their conditioning has been
considered in the light of Hughlings Jackson's
studies on automatism.
