J Neurol (1996) 243 : 633-637
© Springer-Verlag 1996

J. Ghika
J. Bogousslavsky
F. Ghika-Schmid
F. Regli

Received: 26 January 1996
Received in revised form: 17 May 1996
Accepted: 18 June 1996

J. Ghika (5:~). J. Bogousslavsky
F. Ghika-Schmid • F. Regli
Department of Neurology, CHUV,
CH 1011 Lausanne, Switzerland
Fax: 41 21 3145520

"Echoing approval":
a new speech disorder

A b s t r a c t We report the cases of two
patients presenting a peculiar speech
disorder, which we have named
"echoing approval", in which the patients echo, in replying to questions
in a dialogue with short phrases, the
positive or negative syntactical construction of a question, or its positive
or negative intonation, but without
any repetition of whole or part of
sentences. When asked about their
symptoms, the patients replied 80%
of the time with "yes, yes", "that's
right", or "exactly" to positive questions and "no, no" or "absolutely
not" to negative questions, regardless
of their actual symptoms and oblivious to self-contradiction. In addition,
when the examining doctor was
speaking to a medical colleague in
the patient's presence and using
medical terminology that the patient
did not understand, he/she agreed or
disagreed with any sentence and
technical word uttered in a way entirely dependent on the syntax or intonation used. To distinguish this
speech disorder from echolalia or
verbal perseverations, with which it
m a y be superficially confused, we
suggest that it be called "echoing approval", as it may be part one of the
manifestations of the environment-

dependency syndrome. This clinical
picture was found to be associated
with features of transcortical motor
aphasia and frontal lobe signs. One
patient had a bilateral callosofrontal
malignant glioma and the other a
probable multiple system atrophy
with global deterioration, pre-eminent frontal release signs, diffuse
leukoencephalopathy and multiple
lacunes. On the basis of these clinical deficits and neuroimaging features, we are unable to delineate the
common, or minimal, lesioned network required for this symptomatology to occur, especially in the absence
of a series of patients, and with such
a difference in both the location and
causes of the lesions. However, bilateral frontosubcortical dysfunction
was pre-eminent in the clinical picture in both patients, even though
more diffuse brain pathology was
seen in one, and it might be speculated that dysfunction of the bilateral
orbitofrontal and frontomesial motor
frontosubcortical circuits might be
involved in the aetiology of this peculiar speech disorder.
K e y w o r d s Echoing - Speech •
Fronto-subcortical circuit Environment dependency

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Introduction
E c h o l a l i a is g e n e r a l l y f o u n d as part o f the c l i n i c a l p i c t u r e
o f t r a n s c o r t i c a l a p h a s i a and m a y b e d u e to a l e s i o n in the
p o s t e r o m e d i a n f r o n t a l l o b e i n c l u d i n g the s u p p l e m e n t a r y
m o t o r a r e a ( S M A ) [1, 2]. In the g e n e r a l c o n c e p t o f e c h o lalia, s e n t e n c e s , o r f r a g m e n t s o f s e n t e n c e s , are e c h o e d ,
and it is hardly, i f at all, p o s s i b l e to e v a l u a t e v e r b a l u n d e r s t a n d i n g . A s s o c i a t e d s i g n s are f o r c e d g r a s p i n g a n d o t h e r
compulsory phenomena, like utilization behaviour, echopraxia, a n d f r o n t a l r e l e a s e r e f l e x e s . W e r e p o r t t w o p a t i e n t s
w i t h d i f f e r e n t l e s i o n s and c l i n i c a l p r e s e n t a t i o n s , w h o e m p l o y e d an e c h o i n g t e c h n i q u e in d i a l o g u e w i t h the e x a m iner. T h e p a t i e n t s w e r e e x a m i n e d b y e x p e r i e n c e d n e u r o p s y c h o l o g i s t s , w h o m e n t i o n e d " p e r s e v e r a t i o n s " and
" d i f f i c u l t y in u n d e r s t a n d i n g " in t h e i r d e s c r i p t i o n o f b o t h
p a t i e n t s ' s p e e c h . E c h o i n g , as a c o n c e p t , has b e e n app r o a c h e d in studies o f s p e e c h in autistic c h i l d r e n [ 3 - 7 ] ,
but has n e v e r b e e n r e p o r t e d p e r se in adults w i t h a p h a s i a ,
p r o b a b l y b e c a u s e i n s u f f i c i e n t a t t e n t i o n is p a i d to this f o r m
o f s p e e c h , w h i c h m a y s u p e r f i c i a l l y b e m i s t a k e n as a p r o b lem of understanding, perseveration or echolalia.

Case reports
Patient 1 was a 62-year-old right-handed secretary, with the psychological profile of an obsessionally efficient and polite person,
with broad general knowledge, who was referred to a doctor because of recent changes in her personality and work efficiency.
At the beginning of April 1992, her coworkers noticed that she
was sometimes inefficient at work, making errors, missing out
words and having difficulty in understanding orders. She was unaware of any change in either her personality or behaviour, but
complained of headaches and forgetfulness.
On neurological examination, the cranial nerves and fundi were
normal, with no facial asymmetry, orolinguofacial apraxia and no
abnormal cranial reflexes. The rest of the neurological examination was normal, except for an indifferent Babinski sign on the left,
and intermittent extension on the right.
A neuropsychological examination was performed using a
standard battery of tests, and the patient's scores compared with
those for our own population matched for age, gender, level of education and first language [8]. The patient was alert, oriented and
with normal attention scores, as assessed by a normal digit span.
Spontaneous expression was extremely poor, and she would not
talk unless prompted. When speaking, she experienced great difficulty in finding words, but was otherwise fluent; a severe naming
impairment was found on a shortened translation of the Boston
Naming test [8]. There was no agrammatism, no paraphasias, normal prosodia, good articulation, and no jargonophasia, but she
stuttered at times. She could understand three-step orders and positive, negative and passive sentences without difficulty. Repetition
was well preserved. She could read fluently; although her recall of
the text was .poor, there was no confabulation. Her spelling was
unimpaired in a forwards direction but severely impaired in a
backwards direction. Her writing was normal and she understood
words, logatomes, and sentences without difficulty. She had no
constructional or ideomotor apraxia of the right hand, but some degree of apraxia of the left hand on verbal command, suggestive of
callosal dysconnection. Gnosias and visuoperceptive skills (Poppelreuter's embedded figures, mute map, and recognition of famous faces) were intact. The Rey Auditory Verbal learning test

was impaired for recognition, with delayed evocation with scores
in the lower range of the norm. She had massive frontal signs, such
as bilateral grasp, utilization behaviour of any object presented to
her (a purse, a wallet, a telephone, a pen, a glass...), echomimia,
echopraxia, and massive failure of the Stroop test, deficient inhibition of inappropriate responses on a go-no go task, failure to sustain Luria's alternating tasks for both graphic and hand gestures,
and decreased verbal fluency, both in the "M" and "animal" categories.
When asked about her symptoms, the examiner (J.G.) was surprised to receive echoing replies to his questions. For example, the
dialogue would go as follows (it should be explained that translation into English places an apparent contradiction between the syntax of the question and the reinforcing "do you" or "don't you",
which does not exist in French):
"You don't have any trouble speaking, do you?"
"No, no".
"You don't have trouble finding words, do you?"
" No, no. I can find them easily...sometimes, at night, Mr er.,. you
know, sometimes at night, it gets mixed up...".
"Have you noticed any change in your speech?" (purposeful negative intonation)
"No, no".
"But you have noticed that your speech has changed, haven't
you?"
"Yes, yes, oh... yes".
"You do have headaches, don't you?"
"Yes, yes, headaches, very bad headaches .... yes, yes".
"But you just told me you don't have any headaches".
"No, no... no headaches".
"You do know what headaches mean, don't you?"
"Yes, yes headaches, pain in the head, yes, yes.... I have very, very
bad headaches since.., er, since...".
"Do you know what I mean when I say: Kto Ia gavaril (positive intonation)?"
"Yes, kagayavari, yes yes .... yes. I understand very well what it
means, yes, yes".
"Do you know what it means (negative intonation)?"
"No, no, I ' v e no idea what it means, but I can repeat it".
The examiner then turned to another physician and they discussed
her case, while she was sitting between them. One of the physician
says: "We were impressed by the peculiar type of aphasia...".
She says "Yes, yes...yes, exactly, yes, yes".
"... and we thought she had some kind of transcortical, predominantly motor aphasia..."
"Yes, yes, exactly, that's it...".
"...with no phonemic or semantic paraphasia..."
"No, no, absolutely not...".
"...the only abnormal physical signs were bilateral grasping,
echopraxia, and a right Babinski..."
"Yes, yes, that's right..., exactly...".
CT showed a multi|obate bilateral frontal expanding process in the
right paramedian subcortical frontal region and caudate nucleus,
involving the anterior part of the corpus callosum, the subcortical
white matter of the left frontal lobe and the caudate nucleus on the
right side, which was diagnosed as glioblastoma after stereotaxic
biopsy.
Patient 2 was a 71-year-old right-handed, retired highly qualified
worker with obsessional politeness and much self-control, who
was referred to our movement disorder unit because of intellectual
deterioration and trouble with balance and gait. The patient was

635

Figs. 1, 2 Patient 1. CT scan: infiltrative lesion of the right frontal
lobe, striatum, and corpus callosum (glioblastoma)
Figs.3, 4 Patient 2. CT scan: diffuse leukoencephalopathy with
small infarcts in the basal ganglia, especially in the left striatum
(Binswanger's disease?)

unaware of the severity of his condition, except for some forgetfulness and trouble with balance. In his past history there was left
pulmonary lobectomy for a carcinoid tumour in 1972, parathyroidectomy for benign adenoma in 1988, diabetes and hypertension, but he was not diagnosed as having multiple endocrine neoplasia syndrome.
He was seen by a neurologist in 1990 for generalized tremor of
both hands, head and legs, clumsiness of the hands and loss of balance with multiple falls, freezing, and difficulty in changing direction and apraxia in all axial movements, such as rolling over in bed
and getting up from a chair. Handwriting was reduced to his signature, and the fastening of buttons, cutting of meat, shaving and
brushing teeth were extremely slow and difficult. He had noticed
memory problems and had given up driving and let his wife handle
the finances and help him in his daily life. He also complained of
autonomic dysfunction with xerostomia and profuse sweating at
night. He was depressed, with a feeling of a loss of energy, but
there was no sleep disorder or change in appetite. He was taking
levodopa-benzerazide 725 m g q.i.d, without improvement, but he
was never confused or hallucinated. On physical examination, he
was alert, with no fluctuation in vigilance, disoriented in time and
space and anosognosic of most of his condition. There was upgaze

limitation and fractionated pursuit, but no nystagmus or saccadic
oscillation. There was no amimia, hypophonia, or corticobulbar
signs. The blinking rate was normal and there was no facial hyperkinesia. Abnormal nasopalpebral and snout reflexes were elicited.
Both upper and lower extremities showed increased tone, with
cogwheeling, but no brady- or hypo-kinesia. Stereotypia, with
compulsive hand-rubbing, was present. Reflexes were all brisk,
with bilateral Hoffmann and Babinski signs; there were no cerebellar ataxic features except an important postural tremor, and no
signs of peripheral motoneuron involvement. On walking, after
hesitating for a long time (up to 20 s), he took very short steps,
with an intermalleolar distance of 30 cm, feet glued to the floor,
without armswing, and with major instability, retropulsion, 4+ en
bloc turning, freezing and festination of the feet. Some athetosis
and dystonia was visible on both sides.
On neuropsychological examination, this right-handed retired
man was found to have fluctuations in attention, with digit and verbal spans within the lower range of the norm. He had a severe lack
of speech initiation, had to be prompted to say short, mainly
stereotyped sentences, with occasional phonemic and semantic
paraphasia. He had no agrammatism, no dysarthria, and no jargonophasia. Repetition was well preserved. Spelling was impaired,
both forwards and backwards. His performance on the Boston
Naming test was within the lower limits (Lim-C20). Automatic series were possible in their normal order but only partially in the reverse order. He had some difficulty in repeating logatomes (2/5 for
trisyllabic, and 1/5 for polysyllabic), but no problem in understanding even complex three-step oral or written orders, but his
comprehension of passive and negative sentences was impaired.
He could write (with micrography), with some letters missing or
added and dysorthographia. He had occasional paralexia when
reading. He could perform simple oral calculations, but no complex written procedures. He had constructional apraxia, difficulty
m reproducing gestures of no special significance and mild ideomotor and bucolingual apraxia. His discrimination of embedded
figures (Poppelreuter) was poor, as was his orientation on the mute
map. Colour matching, naming and designation were normal. He
had difficulty in recognizing famous faces, and left/right confusion
when looking at the examiner. The auditory verbal learning test
was below the normal range for learning, recognition, and delayed
evocation. He had severe impairment of executive functions with
decreased verbal fluency (l/rain), failure to sustain Luria's alternating tasks (hand gesture and graphic pattern), impaired go-no go
task, and operatory reasoning. W h e n an object was presented, he
would rush towards it, and manipulate it, even if asked not to do
so. Such utilization behaviours would be seen when he was put in
front of a telephone, a pen, a glass of water or a toothbrush, for example. He also had echomimia, echopraxia, visual grasping of mirror, TV sets and patients passing by and "verbal perseveration".
On detailed examination, however, the patient would echo the
questions of the examiner to a point where it was almost impossible to take a valid history. An example of a dialogue with the patient would go as follows:
"Mr X..., do you have any headaches ?"

"No, no".
"But you did tell me you had headaches, didn't you? "
"Yes, yes, that's right".
"Do you know what headache means?"
"Oh yes, yes.., pain in the head, yes, yes".
"Do you have any pain anywhere in your body7"
"No, no pain...never".
"Do you sometimes have cramps?"
"Exactly...".
"Real cramps, such that your muscle gets hard and hurts a lot?"
"Yes, cramps, I have cramps".
"Where?"

636

"In the calf, cramps, yes".
"But you don't have cramps, do you?"
"No,...no".
"You know what cramps are, do you?"
"Yes, yes, cramps, like a big pain in your calf, yes, I have cramps".
"But you just told me that you don't?"
"No, not even...".
"Your main problem right now is balance, isn't it?"
"Exactly...".
"Balance and gait, you understand what I am saying, don't you?"
"Yes, yes, walking, running...".
"And you said that you don't have problems walking, do you?"
"Exactly...".
"Balance and gait, you understand what I am saying, don't you?"
"Yes, yes, walking, running...".
"And you said that you don't have problems walking, running?"
(purposeful positive intonation).
"Yes, yes, exactly".
"But running or walking are not a problem for you, are they?"
(negative intonation).
"No, no...".
CT scan was performed, which showed diffuse cortical and subcortical atrophy, with secondary ventricular dilatation, diffuse
leukoencephalopathy and multiple lacunar strokes in the basal ganglia, which may possibly be compatible with Binswanger's disease. CSF examination was normal, except for a protein level of
1.140 rag/1.

Discussion
Our patients presented a peculiar type of speech disorder,
which has not previously been reported. They both gave
"echoing approval" to a suprasegmental aspect of communication including either the positive or negative syntactic construction of the questions they had been asked,
or to dialogues between two medical colleagues held in
their presence, and also sometimes gave echoing approval
to the positive or negative intonation used to question
them, even when this was deliberately used to produce
conflicting statements. The replies bore no relationship to
their actual complaints or to their own opinion or understanding. They would even contradict themselves within
the space of a few seconds, without any insight or selfcorrection, even when confronted with their own contradictions. Because of the conflicting syntax of the way
questions are asked in English, this speech behaviour may
be less obvious in English, but in languages like French,
German, Spanish, Portuguese or Italian, and maybe many
other languages, in which the affirmative or negative reinforcement at the end of the questions is not so frequently
used, it may be more obvious.
Both patients had a variant form of transcortical motor
aphasia with loss of spontaneity of speech, low fluency
and stuttering, and preserved repetition. Echolalia is often
found in association with transcortical aphasia. One of the
generally accepted explanations for echolalia is a disinhibition, or disconnection, of the acousticomotor reflex

from the SMA, and this is commonly reported in childhood during the development of speech. The absence of
frontal inputs to the speech areas, which account for the
loss of intentionality and voluntary initiation of speech
("aspontaneity" of speech of the transcortical motor aphasia), may disinhibit compulsory speech production induced by sensory inputs from the parietal lobes [2, 11,
12]. The integrity of the posteromedial part of the frontal
lobe seems to be a prerequisite for normal reaction to
speech stimuli received from the Wernicke area [2]. The.
most anterior part of the medial subcallosal fasciculus, at
the lateral angle of the frontal horn of the lateral ventricles, deep to Broca's area, contains the projections from
both the cingulate g y m s area 24 and the SMA to the caudate nucleus [14-17], and therefore the afferent loop of
the circuit to the cortical speech areas. A similar mechanism of disinhibition or disconnection, at another level of
speech processing, could be accepted for echoing approval, but in contrast to echolalia patients do not repeat
words or sentences in echoing approval [1, 2].
Echoing approval also differs from perseverations because of the absence of repetitive non-inhibited words, or
parts of sentences, in response to different questions [10].
However, in oroverbal perseverations, San Pietro and
Rigrodsky [10] distinguished between patterns including
semantic selection, programme of action and phonemic
carry-over, none of which can be used for anterior or posterior localization in the frontal lobe. A semantic selection
deficit would only partly account for the speech disorder
described here, because prosodic selection would, at
times, predominate over semantic echoing. Verbal iterations and perseverations with ideation and semantic incoherences have also been described in patients with lesions
of the left putaminocaudate nuclei [17, 18].
Deficits in understanding can definitively not explain
the answers of the patients, as understanding was not significantly impaired and the answers were not random. Although some similarity with the "feeling tone" often seen
in aphasic patients can be mentioned, the understanding
of even complex speech was preserved in both patients.
A major attention deficit could also be ruled out, as the
attention tests were normal in the first patient and only
mildy impaired in the second. Confabulation can. also
been ruled out as an explanation for echoing approval, as
it was absent in both patients.
Our patients' speech disorder shares striking similarities with echoing motor behaviours described by Lhermitte in the the environmental-dependency syndrome
[ 11 ]. Echopraxia, echomimia, and environment-driven behaviours [11-13] were in fact found in both patients, and
our speech disorder may be considered as a form of an
echoing behaviour of speech, different from echolalia,
with echoing to both the semantic and prosodic aspects of
speech. An interesting finding is that of real dissociation
between the patients' echoing responses to prosody of
sentences and their ignorance of the semantics, especially

637

since c o m p r e h e n s i o n was largely intact, w h i c h is consistent with the significant a n o s o g n o s i a f o u n d in both patients. In e c h o p r a x i a , e c h o m i m i a , and e n v i r o n m e n t a l dep e n d e n c y s y n d r o m e , a d y s f u n c t i o n o f the frontosubcortical orbitofrontal and d o r s o l a t e r a l circuits has b e e n postulated [13]. In our first patient, the h e a d o f the caudate nucleus was i n v o l v e d , but on the right side, t o g e t h e r with the
anterior part o f the corpus callosum, and subcortical
frontal white matter, i n c l u d i n g the subcortical c o n n e c t i o n
to the S M A . T h e s e c o n d patient h a d clinical d y s f u n c t i o n
o f both striata, a c c o u n t e d for b y his p r e - e m i n e n t levo d o p a - r e s i s t a n t p a r k i n s o n i s m and m u l t i p l e lacunes in the
striatum, but also a m o r e diffuse l e u k o e n c e p h a l o p a t h y and
lacunar infarcts in the thalami, w h i c h a c c o u n t e d for a
m o r e g e n e r a l i z e d pathology, m a k i n g it difficult to delineate the strategic d e f e c t i v e n e t w o r k at the origin o f our
speech disorder. In patient 1, however, no lesion was
found outside the frontal, striatal and callosal regions.
T h e s e findings are c o m p a t i b l e with a bilateral fronto-subcortical d y s f u n c t i o n in several o f the loops d e s c r i b e d b y

A l e x a n d e r et al. [13], i n c l u d i n g s o m e d i s c o n n e c t i o n in the
orbitofrontal, dorsolateral and f r o n t o m e s i a l m o t o r l o o p
that is p o s s i b l y r e s p o n s i b l e for the e n v i r o n m e n t a l depend e n c y s y n d r o m e d e s c r i b e d b y L h e r m i t t e [11, 19].
In conclusion, w e describe a n e w pattern o f speech disorder, w h i c h b e l o n g s to the b r o a d group o f " e c h o " phenomena. W i t h o u t p a t h o l o g i c a l studies on our two patients,
it is not p o s s i b l e to define m o r e p r e c i s e l y the n e t w o r k o f
lesions n e e d e d for the o c c u r r e n c e o f " e c h o i n g a p p r o v a l " ,
but frontal deficits were the outstanding features in the
clinical picture, together with transcortical m o t o r aphasia.
Both patients also s h o w e d clinical and/or r a d i o l o g i c a l evi d e n c e o f bilateral frontostriatal i n v o l v e m e n t , w h i c h could
indicate that the d y s f u n c t i o n o f the f r o n t o s u b c o r t i c a l circuits d e s c r i b e d b y A l e x a n d e r , i n c l u d i n g the 0rbitofrontal,
dorsolateral and f r o n t o m e s i a l circuits, m i g h t p l a y a role in
this clinical picture, as in other forms o f e n v i r o n m e n t - d e p e n d e n c y s y n d r o m e s [ 11-13] and the transcortical m o t o r
a p h a s i a f o u n d in both patients.

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