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17 février 2007 
J Mental Science
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).
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.
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.