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J Neurol Neurosurg Psychiatry 2000;68:224–226

SHORT REPORT

Forced hyperphasia and environmental
dependency syndrome
Yutaka Tanaka, Martin L Albert, Hitoshi Hara, Takeshi Miyashita, Noriko Kotani

Neurology, Momose
Clinic, 124 Shimogaito,
Heguri-cho,
Ikoma-gun, Nara,
636–0933 Japan
Y Tanaka
Harold Goodglass
Aphasia Research
Center, Department of
Neurology, Boston
University School of
Medicine, and Boston
Veterans
Administration
Medical Center, MA,
USA
M L Albert
Department of
Cerebrovascular
Medicine, Yodogawa
Christian Hospital,
Japan
H Hara
T Miyashita
N Kotani
Correspondence to:
Dr Yutaka Tanaka,
Neurology, Momose Clinic,
124 Shimogaito, Heguri-cho,
Ikoma-gun, Nara, 636–0933
Japan
email EZZ05540@nifty.ne.jp
Received 26 May 1999 and
in revised form
8 September 1999
Accepted 17 September 1999

Abstract
A distinctive, language related fragment of
the environmental dependency syndrome
is described: compulsive, involuntary,
environmentally dependent speaking. Because this syndrome represents the obverse of aphasia, it is named forced
hyperphasia. An 84 year old woman with
acute left frontal infarction was admitted
to hospital with gait disturbance, forced
grasp reflex, and striking imitation behaviour. After 2 weeks her imitation behaviour
disappeared, but an equally striking new
behaviour emerged. In the presence of
others she would call out the names of
objects in the room, and also call out the
actions and gestures of people in the room,
even though she was not asked to do so,
and even though she was asked to stop. For
example, if the doctor scratched his nose,
she said, “The doctor is scratching his
nose.” Brain CT, MRI, and SPECT showed
cerebral atrophy and a left superior frontal
subcortical infarct. It is suggested that
“forced hyperphasia” is a clinical fragment of the environmental dependency
syndrome and that her compulsive, impulsive, involuntary release of spoken language resulted from the release of frontal
inhibition of the complex reflex linking
environmental cues to the set of motor,
limbic, spatial, and linguistic associations
underlying spoken language.
(J Neurol Neurosurg Psychiatry 2000;68:224–226)
Keywords: forced hyperphasia; imitation behaviour;
environmental dependency syndrome

The syndromes of “imitation behaviour,” “utilisation behaviour,” and “environmental dependency” were described by Lhermitte and
colleagues in a series of presentations, video
demonstrations, and publications in the
1980s.1–5 Since then, these striking clinical phenomena have been abundantly detailed.6–12
The term “utilisation behaviour” is applied
to a peculiar pattern of actions, linked to frontal lobe dysfunction, in which patients display
an exaggerated dependency on the environment for behavioural cues. When an object is
placed before them they tend to act on that
object (for example, use a hammer, pour water
from a pitcher, write on a piece of paper), even

when told not to, and even when they admit
that they were told not to.
The term “imitation behaviour” refers to a
condition in which patients imitate the gestures
and behaviour of an examiner, even when
asked not to. Imitation behaviour is considered
to be a milder version of utilisation behaviour,
and both are part of the more comprehensive
environmental dependency syndrome.
In this report we describe a distinctive,
language related fragment of the environmental dependency syndrome: compulsive, involuntary, environmentally dependent speaking.
We describe an elderly woman who was unable
to prevent herself from speaking about objects
or events in her immediate environment, even
though she was asked not to. Because this
clinical phenomenon contrasts with aphasia
and resembles the syndrome of compulsive
writing called “forced hypergraphia”,13 we propose the term “forced hyperphasia”.
Case report
An 84 year old, right handed woman was
admitted to the hospital for evaluation of
memory impairment and gait disturbance. One
month before admission she had sudden onset
of right sided weakness. After that episode she
developed increasing complaints of memory
impairment and gait disturbance.
Positive neurological findings on admission
included bilateral grasp reflexes with forced
visual groping with the right hand (visual grasp
reflex). She also had other evidence of frontal
system dysfunction, including snout, suck, and
palmomental reflexes. She had a mild right
hemiparesis; she could not walk unaided; deep
tendon reflexes were increased bilaterally; Babinski’s sign was present on the right. Pain sensation was decreased on the right.
Orientation to time, place, and person was
within normal limits. Speech output was fluent
with phonemic paraphasias. Repetition was
limited to short sentences. She could not follow
simple spoken commands, such as “open your
mouth.” She had recurrent perseveration. She
could read and carry out written commands.
She was agraphic for Kana and Kanji. Writing
to dictation for Kana letters was 80% accurate;
for Kanji letters, 40%; and for simple sentences, 80%. Written picture descriptions were
50% accurate. Writing, both to dictation and
on written picture description, was large,

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Forced hyperphasia and environmental dependency syndrome

to prevent herself from carrying out the imitation behaviour.
FORCED HYPERPHASIA

FLAIR (fluid attenuated inversion recovery) image of MRI demonstrating the left frontal
subcortical infarction.

crude, and poorly constructed in both Kana
and Kanji. In addition to these mechanical
abnormalities, there was a tendency to agrammatism, especially in the omission of function
words. However, her ability to copy was virtually intact.
Mini mental state examination on the 30th
hospital day was 17/30. Score on the Wechsler
memory scale (R) was 40/100, with orientation
8/20 (orientation for time and place was
normal), Calculation 12/20, story recall 6/20,
digit span 8/10, and paired word recall 6/30.
Score on the Raven’s coloured progressive
matrices was 17. The standard language test
for aphasia (Japanese aphasia battery) performed on the 40th hospital day showed word
finding diYculty and impairments on tests of
word generation.
NEURORADIOLOGICAL EXAMINATIONS

On admission her brain CT and MRI (figure)
showed, in addition to cerebral atrophy, a left
superior frontal subcortical infarction. Magnetic resonance angiography (MRA) showed
total occlusion of the left anterior cerebral
artery, 90% stenosis of M1 portions bilaterally,
and bilateral stenosis of posterior cerebral
arteries. On the 14th hospital day 123I single
photon emission tomography (SPECT) demonstrated hypoperfusion of left frontal and
temporal areas.
IMITATION BEHAVIOUR AND FORCED GRASPING

She displayed the forced grasp reflex behaviour
commonly described in patients with frontal
lobe lesions and imitation behaviour. Any
objects touching her right hand, such as her
bed sheets, would be grasped. Even by the 30th
hospital day she still manifested visual forced
grasp on the right.
Initially, she exhibited involuntary imitation
behaviour. When a doctor, standing by her
bedside, touched his chin, she would touch her
chin. When he touched his hair, she would
touch her hair. If he raised his hand, she would
raise her hand. If he waved, she would wave.
She imitated all behaviours of doctors and
nurses in the room, even when asked not to.
When asked why she did this, she said she felt
she had to. When asked to stop, she was unable

After 2 weeks in the hospital her imitation
behaviour disappeared, but, only in the presence of others, she began to call out the names
of objects in the room, even though she was not
asked to do so, and even after she was asked to
stop. She also spoke out impulsively to name or
describe actions and gestures of people in the
room, even though not instructed to do so, and
even after being asked to stop. For example, if
a doctor touched his chin, she said, “The doctor is touching his chin.” If he touched his hair,
she said, “The doctor is touching his hair.” If an
examiner waved his hand, she said, “The doctor is waving his hand.” This “speaking out”
behaviour was impulsive, compulsive, involuntary, and apparently, unstoppable. She never
repeated the sentences of the examiner unless
so requested.
By the 30th hospital day, her forced
hyperphasia disappeared.
Discussion
We think that forced hyperphasia is a language
linked fragment of the environmental dependency syndrome. Patients with frontal lobe
damage have been described as being “pulled
to stimulus”.14 15 Imitation behaviour and utilisation behaviour seem to be complex forms of
“pull to stimulus.” Forced hyperphasia, first
described to our knowledge by Shimomura et
al,16 probably falls within the same neurobehavioral family.
“Pull to stimulus,” of course, is simply
another descriptive term for a behaviour which
has been diYcult to explain. The best current
explanation, in our opinion, is that this behaviour is a complex reflex resulting from release
of frontal inhibition. Among the functions of
the frontal lobes is inhibition of inappropriate
motor, limbic, and spatial responses which
might impulsively be released as a reaction to
disturbing or irrelevant stimuli. Such behaviour, a “pull to environmental stimulus,” is
universal in infants. As the frontal lobes
mature, instinctive, involuntary, reflex “pull to
stimulus” is inhibited; the sensorimotor and
association systems develop ever more complex, controlled interactions with the environment. A neurally based “social grammar” is
developed whereby cognitive and emotional
systems are integrated with the environment,
and we develop the capacity to control our
environment and plan ahead. The “social
grammar” is the internalised, neurally conditioned set of rules which order and constrain
interactions between and among people and
their environment(s). Impulsive, inappropriate,
environmentally linked, complex reflex responses are released when frontal inhibitory
systems are damaged.
Why don’t we see environmental dependency syndromes (forced hyperphasia, forced
hypergraphia, visual grasp reflex, imitation
behaviour, utilisation behaviour) more often?
Most likely the “social grammar”—that is, the
rules whereby the brain interacts with the envi-

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Tanaka, Albert, Hara, et al

ronment is multilayered in interlocking neural
nets, widely distributed throughout the brain.
Focal damage to the frontal lobes without more
widespread damage to the neural substrate
underlying the “social grammar” may not be
suYcient to cause an environmental dependency syndrome. Lhermitte made the point that
“loss of intellectual control” was required for
the occurrence of such behaviour. Our patient
had not only the frontal lobe lesion but also
damage in other portions of the brain.
Shimomura et al16 described what we are calling
forced hyperphasia in patients with dementia of
the frontal lobe type. Exploration of the neurobiology of rules whereby the brain interacts
with the environment (the neurology of the
“social grammar”) should be a fruitful endeavour.
We thank Ms M Aoki of the Yodogawa Christian Hospital for
administering the cognitive examinations.
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