Echopraxia

The term "echopraxia" refers to imitative automatism, involuntary repetitive acts in which a person reproduces facial expressions, postures, gestures, word combinations or individual words made or said by others. The pathological syndrome is inherent in patients suffering from schizophrenia (the so-called catatonic symptom), or intense organic brain damage and oligophrenia.

Echopraxia is practically identical in speech therapy, psychology, and psychiatry, as it means involuntary repetition of anything, including sounds, words, phrases, and actions. The term also has clearer subdivisions as "echolalia" or "echophrasia" (repetition of sounds, words and phrases), "echomimia" (repetition of other people's facial expressions). Another possible name for echopraxia is echokinesia (literally translated as "repetition of movements").

Epidemiology

The prevalence of echopraxia is approximately 6%, predominantly in children between the ages of 5 and 11 years.

Organic brain lesions, pathologies of the pre and perinatal period most often predispose to pathology.

Natural, physiologic echopraxias are noted in young children, according to different data - with a prevalence of 10 to 55%. After reaching 3 years of age, such phenomena are normally leveled without any consequences.

The incidence of echopraxia in individuals who have experienced various psychological traumas (war, terrorist attacks, etc.) is noted in the range of 30%. The incidence of this disorder in peacetime may be 0.5% in adult male patients and slightly more than 1% in adult female patients. The majority of echopraxia episodes were noted not at the immediate moment of stress, but in a remote period, after the person had recovered from the stressful event.

Causes of the echopraxias

Echopraxia is not always a pathological symptom. Sometimes it is just a manifestation of an imitative reflex (imitation reflex), which can be actively observed in early childhood, when children are trying to master elements of speech, household and other skills. In this situation, echopraxia is physiological in nature, but at a certain stage it must be replaced by other developmental mechanisms. If this does not happen, we can talk about the disinhibition of the imitative reflex and the formation of pathological echopraxia.

Let's take a closer look at the most likely physiologic and pathologic causes of echopraxia.

• Physiological causes are inextricably linked to the active development of the child, using the imitation of adults. Gradual acquisition of the necessary skills leads to the leveling of signs of echopraxia, but this period can have a different duration, which is due to a number of factors:
  • insufficient sources of skills (when a toddler does not know exactly how he or she should say or do something, he or she begins to simply copy what is seen or heard and repeat these actions);
  • lack of understanding of individual actions or mechanisms, or lack of the necessary constructive sequence (due to the same lack of understanding);
  • stressful conditions experienced or currently being experienced (may be associated with a sudden change of environment, the need to communicate with strangers, the loss of loved ones, etc.);
  • habitual automatisms (we are talking about conscious repetitions, following established patterns, which is most often caused by insufficiently formed skills of self-control and self-regulation).
• Pathological causes are related to neurological and psychiatric pathology, and can manifest themselves both in childhood and adulthood. The later appearance of the problem is typical of mental disorders, damage and abnormal development of the brain lobes responsible for controlling activity. Among the most common pathologic causes are the following:
  • Autistic disorders, infantile autism. Automatisms in the form of repeated episodes of echopraxia act as a way of self-regulation of behavioral and emotional manifestations. In addition, echopraxia is characteristic of communicative disorders - in particular, Asperger's syndrome.
  • Oligophrenia, mental retardation. Echopraxia in intellectual retardation helps to compensate for missing skills.
  • Schizophrenia, catatonic syndrome (in particular, catatonic stupor).
  • Organic brain disorders (Pick's disease, cerebral circulatory disorders, vascular atherosclerosis, etc.).
  • Hereditary neuropsychiatric pathologies, Tourette's and Rett's syndromes (cerebroatrophic hyperammonemia), etc.

Risk factors

The clear factors of echopraxia are not fully elucidated. Presumably, all sorts of biological, social, psychological aspects make a certain contribution. In many cases, echopraxia is provoked by a combination of several circumstances at the same time.

Risk factors include hereditary predisposition, tendency to depressive states, pathological addictions. A special role is played by negative life events, abrupt change of place of residence (emigration), restriction of freedom, traumatic situations (especially childhood traumas), loss of relatives and close people, violence, separation from the family and so on. In addition, among the common factors are excessive emotionality, impulsiveness.

Echopraxias are frequently detected in patients with these pathologies:

• autism;
• attention deficit hyperactivity disorder;
• bipolar affective disorder;
• schizophrenia;
• depressive states.

The risk of developing echopraxia is increased due to craniocerebral traumas of varying severity, viral infections, substance abuse. Peculiarities of pregnancy and childbirth are also important.

The influence of social factors, including abuse, violence, and other traumatic events, has been identified.

Pathogenesis

The pathogenesis of echopraxia development is based on disinhibition of the imitative reflex, possible damage to the left cerebral hemisphere (in particular, the frontal lobe). When assessing the pathogenetic mechanism, it is necessary to take into account individual features of the organism, possible hereditary predisposition, age, sex, biological phase, residual manifestations of the transferred diseases. Such factors often impose their imprint on the peculiarities of the course of echopraxia.

In general, echopraxia is predominantly not an independent pathology, but a specific symptom that correlates with and is causally related to a particular disease.

Echopraxia may be a reaction to severe or prolonged stress or severe anxiety. A possible connection of the disorder with affective disorders and other psychopathologies characterized by severe anxiety has been described. Unfortunately, there is no unanimous opinion on the pathogenetic mechanism of echopraxia development in such situations.

Symptoms of the echopraxias

Echopraxias are characteristic of the state of catatonic excitation. The person is marked by pronounced dissociation, paradoxical and inadequate disturbances in the connection of internal mental and motor processes. One of the successive stages of catatonia is impulsive excitation. It is characterized by unconventionality of actions (sudden jumps, screams, destructive actions), echopraxias, perseverations.

Repetition of words and movements of others may be accompanied by pretentiousness, grimacing.

In post-traumatic stress disorders, sleep disorders, unmotivated attacks of irritability and irascibility, memory impairment, decreased concentration of attention are in the foreground. Echopraxia may occur against the background of depression, anxiety.

In the absence of obvious aggravating psychological factors, there may be little physiological disorders - in particular, digestive disorders, hiccups, difficulty breathing, or other signs, in general, do not violate the basic physiological functions of the body.

Emotional disturbances typical of the pediatric age group:

• anxiety and emotional disorders;
• phobias;
• social anxiety disorders, etc.

The catatonic syndrome is characterized by movement disorders that manifest themselves as both states of agitation and immobility (stupor). Muscular tensions are unmotivated - that is, they have no relation to the situation or other psychopathologic syndromes. The first signs of the development of the pathological state are quite typical:

• impulsive activity;
• Mutism (unwillingness to speak despite full health of the speech mechanism);
• negative, meaningless, opposition, or complete unwillingness to act (more often the patient does the opposite of what is necessary);
• motor and speech repetitions, flamboyant movements and facial expressions.

Imitative (echoic) signs are manifested as echopraxia, echolalia, echomimia, and echophrasia. Echopraxia and perseveration in such a situation should be distinguished as a separate symptom. Thus, perseveration is said about persistent repetition of a separate phrase, action, emotion. As an example - persistent repetition of a particular word, both orally and in writing. Perseveration is called exactly "getting stuck in the head" of any action or word: the patient repeatedly repeats, regardless of the essence of the questions or requests. Echopraxia is the same repetition, but imitative: the patient repeats simple actions or speech near or in front of him.

Echopraxia in children

Echopraxia - especially in the form of repetition of words or word combinations - is often observed in babies up to 1.5 years of age. With the growth and development of the child, such manifestations are leveled out, and they cannot be considered pathological. Pathology is said if echopraxia persist after the baby reaches 2-3 years of age. It becomes noticeable that children do not acquire their own skills (motor, speech), but repeat the actions of close and surrounding people: parents, grandparents, older sisters and brothers.

Echopraxias may be considered automatisms, but such repetitions are not meaningless. They help the patient to indicate some actions or phenomena, to support activity or communication, and to express his or her understanding of anything. For example, children with autism spectrum disorders are characterized by stereotypy, behavioral repetition, which is manifested by stereotypical movements, building a strict order of toys and so on. Such children use automatisms in different aspects: to stabilize the emotional background, for their own stimulation (repetitions cause an excited reaction).

To diagnose a child, echopraxia must be pronounced, persistent (lasting 6 months or more), accompanied by other pathologic signs, and negatively affect important areas of daily activity.

Stages

In their practice, specialists rarely use the classification of echopraxia. However, a distinction is made between pathologic and physiologic echopraxia, mild and advanced stages of the disorder.

Could be dating:

• Echopraxia caused by other psychiatric pathologies. In such a situation, we can talk about schizophrenia, catatonic syndrome, affective disorders, obsessive-compulsive disorder, autism.
• Echopraxias caused by somatic diseases. This list includes pathologies mainly with metabolic, infectious and neurological disorders.
• Echopraxia unspecified. In this case, we are talking about disorders in the development of which no connection with any psychopathology or somatic diseases is found.

Separately, we can distinguish echopraxias that occur as a result of taking psychostimulant drugs and substances.

Forms

Depending on the clinical manifestations, echopraxia can be immediate (immediate) or delayed.

The immediate variant is expressed by the patient unconsciously repeating an action or phrase he or she has just seen.

In the delayed variant of the disorder, there is a repetition of an action noted not just now, but some time later (for example, an element previously seen or heard in a game or program is reproduced).

Complications and consequences

Most of the adverse effects of echopraxia are due to untimely identification of the causes of the disorder or incorrect treatment tactics for the disorder.

The likelihood of complications depends on the underlying cause of echopraxia. In severe forms of schizophrenia, catatonia can develop such problems as:

• deep vein thrombosis, pulmonary embolism (due to prolonged immobility);
• pneumonia (as a result of difficulty in eating in patients with mutism and the risk of aspiration of food particles);
• metabolic disorders, dehydration and exhaustion (in case of prolonged inattentiveness of patients).

In general, with an adequate approach to treatment, complications are rare. Recurrences of echopraxia are observed mainly in idiopathic variation of the pathology, as well as in disorders arising against the background of affective disorders.

The main condition for preventing adverse effects is timely diagnosis of the disease and immediate implementation of appropriate therapy.

Diagnostics of the echopraxias

The conclusion about the presence of pathologic echopraxia should take into account the age and developmental level of the patient. For example, episodic small echopraxias are an adequate part of the development of a 2-3 year old child, and their temporary isolated presence alone should not be the basis for a diagnosis.

The suspicion of a disorder and the need for additional diagnostics may arise:

• with signs of mania, schizophrenia;
• with a general developmental disorder;
• for hyperkinetic disorders and depression.

Echopraxia is diagnosed after some communication and observation of the patient. This is usually not difficult, unlike finding the underlying cause of the disorder.

Laboratory tests are rarely prescribed, as their indications are nonspecific for this type of disorder. Conducting endocrine tests (dexamethasone, stimulation of thyroid hormone production) is indicated mainly to assess the effect of treatment of depressive states. But complex instrumental diagnostics is recommended as part of the following measures:

• assessment of the state of internal organs to identify the relationship between somatic diseases and psychopathologies;
• detection of somatic contraindications for the prescription of psychotropic and other drugs;
• timely diagnosis of side effects and complications.

Tactics commonly used to elucidate the cause of echopraxia include:

• Mental and neurologic status is assessed by history taking, neurologic examination and interview.
• Examine motor and speech skills, determine their degree of development, and identify deficits and gaps in development.
• Conduct specific neuro and psychological testing to assess memory, concentration, intellectual and thinking processes. Determine the likelihood of organic lesions of the central nervous system, mental retardation.
• Differentiate neurologic pathologies.

Differential diagnosis

If echopraxia is detected, the following pathologies and conditions should be excluded in the patient:

• schizophrenia;
• manic-depressive psychosis;
• brain infections accompanied by psychiatric disorders;
• the effects of head injuries;
• vascular diseases of the brain (hypertension, cerebral atherosclerosis);
• brain tumors;
• somatic diseases and common infections;
• mental disorders of the elderly;
• primary degenerative (atrophic) processes in the brain;
• alcoholism, drug abuse and substance abuse;
• reactive psychoses;
• neurotic disorders;
• psychosomatic disorders;
• personality and emotional disorders;
• mental retardation and mental retardation.

Treatment of the echopraxias

Elimination of echopraxia without treatment of the underlying disease is impossible. Therefore, complex therapy is prescribed, taking into account the underlying cause of the disorder. Correction of echopraxia directly is carried out with the involvement of a psychotherapist, psychologist, speech therapist, defectologist, depending on the features of the pathology.

Medications, especially in children, are used sparingly. In each individual case, the decision on drug therapy should be made on a well-founded basis, with clear indications. Such caution can be explained by the fact that there is no complete picture of the pharmacological effects of drugs on the immature brain system and the developing organism. Possible side effects, including long-term effects, are also taken into account.

When schizophrenia is diagnosed, antipsychotics such as Amisulpride, Risperidone, Olanzapine are prescribed. At the same time, cognitive-behavioral and family psychotherapy, occupational therapy, social rehabilitation are carried out. In addition, neuroleptics, antidepressants, nootropic drugs may be used as indicated.

Sessions with psychologists and psychotherapists are conducted using special exercises, games, video and audio materials through which the patient is encouraged to practice replacing the echopraxia response with other actions or stimuli. Gradually, the sessions are lengthened in time and complexity, and group counseling is added.

Prevention

An important preventive moment is the prevention of brain damage at the initial stage of ontogenesis. In this regard, it is necessary to carefully take care of a woman's health during pregnancy, to provide a nutritious diet, positive emotions, which contributes to the formation and birth of a healthy baby. With poor nutrition, regular stress and depression during pregnancy, the vulnerability of the central nervous system of the fetus increases significantly.

If there is hereditary aggravation, experts recommend planning a pregnancy in advance - at least 3-6 months in advance. Until then, it is necessary to carry out a complete diagnosis, treat existing diseases, normalize weight, eliminate alcohol consumption and smoking.

Infectious pathologies occurring during pregnancy - in particular, influenza, coronavirus infection, rubella, poliomyelitis - adversely affect the development of the brain of the future child.

Negative obstetric factors contributing to the predisposition to echopraxia in the child include immunologic incompatibility, fetal oxygen deprivation, birth trauma, low birth weight, and preeclampsia.

In adolescence and older age, it is important to completely eliminate the use of alcohol and drugs. Persons with a predisposition to echopraxia should, if possible, develop social skills, avoid social isolation, and cultivate optimistic attitudes. The practice of specific trainings aimed at avoiding stress and depression is recommended. It is necessary to maintain stability and calmness in the family, avoid emotional outbursts (shouting, quarrels, etc.) and, even more so, physical violence. It is important to develop conflict resolution skills in children as early as possible.

Other not insignificant preventive points:

• physical activity;
• Stress management practices;
• social participation, formation of friendships, mutual assistance.

Forecast

The prognosis of echopraxia varies. Positive trends are seen if:

• the patient is able to make and maintain contact throughout the session;
• no obvious behavioral or emotional disturbances;
• the patient can communicate, hold a conversation, with a sufficient degree of intelligence to do so.

In general, echopraxia is not a fatal progressive pathology. Many patients have a relatively favorable course, especially if the disorder develops at a relatively advanced age and as a result of certain traumatic events. A good prognosis is expected in people who are successful in work and study, have an adequate level of education, socially active, well adapted to different life situations. Another significant factor influencing the course of echopraxia is the timeliness of qualified specialist help.