Second edition

04.qxd 3/10/08 9:33 AM Page 121
asked “How are you today?” replied “I am very well, thank
you, thank you, thank you, thank you . . .” up to six times
with increasing speed and decreasing volume.’
Etiology
Palilalia occurs in Parkinson’s disease (Benke et al. 2000),
progressive supranuclear palsy (Kluin et al. 1993), Tourette’s
syndrome (Cardoso et al.), and in advanced Alzheimer’s disease
(Cummings et al. 1985). There are also rare case reports
of palilalia in multi-infarct dementia (Serra-Mestres et al.
1996), thalamic infarction (Yasuda et al. 1990), and as one
manifestation of complex partial status epilepticus (Linetsky
et al. 2000).
Differential diagnosis
Verbal perseveration is distinguished by the fact that the
repeated word or phrase is spoken without the distinctive
increasing rapidity and decreasing distinctness.
Stuttering is distinguished by the fact that it is the first letter
of a word that is repeated, and echolalia by the fact that in
echolalia what is repeated is not something the patient spoke
but rather what the examiner or another person said.
Treatment
Treatment is directed at the underlying condition. In a case
of palilalia occurring as part of a multi-infarct dementia,
trazodone was effective (Serra-Mestres et al. 1996);
whether this would carry over into other conditions is not
known.
4.5 PERSEVERATION
Perseverative speech or behavior (Sandson and Albert
1987) is commonly seen in a variety of conditions, most
notably dementia.
Clinical features
Perseverative speech generally occurs in one of two forms.
In one, termed recurrent, patients supply the same response
to repeated, but different, questions. For example, one
patient, when asked where she was, replied ‘Louisville;’
when asked next what year it was, she perseverated in her
response, and again said ‘Louisville.’ The other form is
termed continuous and here, without being prompted,
patients repeat the same word or phrase again and again.
One of Kinnier Wilson’s (Wilson 1954) patients with Pick’s
disease ‘repeated endlessly, “I want my husband and my
children and I don’t know where they are.” ’
4.6 Primitive reflexes 121
Perseverative behavior may involve drawing, writing, or
other motor activity. After being asked to draw a stick figure
one patient did so and then drew multiple others until
the page was filled. Another patient who was asked to write
his name wrote out ‘Paul’ and then perseverated with the
letter ‘l’, until he reached the edge of the page. In another
case, a patient, after being asked to get dressed, went to the
closet, took out a pair of pants, then paused and hung them
back up, then took them out again, and repeated the
sequence until being asked to stop.
Etiology
Perseveration is common in dementia (Bayles et al. 1985),
especially frontotemporal dementia (Thompson et al. 2005),
Alzheimer’s disease (Bayles et al. 2004), and diffuse Lewy
body disease (Doubleday et al. 2002). It is commonly seen in
delirium, and is also an integral part of the frontal lobe syndrome.
Other conditions characterized by perseveration
include aphasia (Albert and Sandson 1986), autism
(Rumsey et al. 1986), schizophrenia (Siegel et al. 1976), and
traumatic brain injury (Hotz and Helm-Estabrooks 1995).
Differential diagnosis
Palilalia is distinguished by the fact that the verbal repetition
has a distinctive character to it, in that the repeated
word or phrase is said with increasing speed and decreasing
distinctness.
Stereotypies represent a subset of perseverative motor
behavior wherein the repeated behaviors are distinctly purposeless
and monotonous. In many patients with dementia,
schizophrenia or autism, both purposeful and stereotypical
perseveration may appear.
Treatment
Perseverative behavior may lessen or remit with treatment
of the underlying condition. In one unblinded study,
bromocriptine reduced perseverative behavior in dementia
(Imamura et al. 1998).
4.6 PRIMITIVE REFLEXES
Normal infancy is characterized by numerous reflexes that,
in the usual course of events, tend to fade or disappear with
development; these may, however, be found in adults, and
in such cases they are known as ‘primitive’ reflexes. Although
these reflexes are found in certain pathologic conditions,
such as dementia, they may also, as noted below, be found
in normal individuals, and hence care must be taken in
their interpretation.
Primitive reflexes are also known as developmental
reflexes; ‘frontal release signs’ constitutes another synonym.