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Repetitive Speech Phenomena in Parkinson's Disease

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Repetitive Speech Phenomena in Parkinson's Disease J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.69.3.319 on 1 September 2000. Downloaded from J Neurol Neurosurg Psychiatry 2000;69:319–325 319 Repetitive speech phenomena in Parkinson’s disease Th Benke, C Hohenstein, W Poewe, B Butterworth Abstract higher number of repetitive speech phe- Objectives—Repetitive speech phenom- nomena over semiautomatic forms of ena are morphologically heterogeneous speech. iterations of speech which have been Conclusions—In idiopathic Parkinson’s described in several neurological disor- disease repetitive speech phenomena ders such as vascular dementia, progres- seem to emerge predominantly in a sub- sive supranuclear palsy, Wilson’s disease, group of patients with advanced disease and Parkinson’s disease, and which are impairment; manifest dementia is not a presently only poorly understood. The necessary prerequisite. They seem to rep- present, prospective study investigated resent a deficit of motor speech control; repetitive speech phenomena in Parkin- however, linguistic factors may also con- son’s disease to describe their morphol- tribute to their generation. It is suggested ogy, assess their prevalence, and to that repetitions of speech in Parkinson’s establish their relation with neuropsycho- disease represent a distinctive speech dis- logical and clinical background data. order, which is caused by changes related Methods—Twenty four patients with ad- to the progression of Parkinson’s disease. vanced Parkinson’s disease and 29 sub- (J Neurol Neurosurg Psychiatry 2000;69:319–325) jects with mid-stage, stable idiopathic Keywords: Parkinson’s disease; repetitive speech phe- disease were screened for appearance, nomena forms, and frequency of repetitive speech phenomena, and underwent a neuro- psychological screening procedure com- Patients with Parkinson’s disease often present prising tests of general mental with a complex impairment of speech, com- functioning, divergent thinking and monly recognised as dysarthrophonia.1–6 It is memory. Patients with advanced Parkin- generally accepted that parkinsonian dysar- son’s disease had a significantly higher thria emerges due to neurogenic impairments disease impairment, longer disease dura- at the respiratory, phonatory, and articulatory tion, and an unstable motor response to level. Based on an earlier proposition by levodopa with frequent on-oV fluctua- Leyser,7 Critchley8 has classified the speech tions. Both groups were well matched as to disorders of patients with Parkinson’s disease their demographical, clinical, and cogni- into akinetic, rigid, hyperkinetic, and iterative tive background. Perceptual speech evalu- (or repetitive) forms of dysarthrophonia. This ation was used to count and diVerentiate symptomatic classification suggests that the http://jnnp.bmj.com/ forms of repetitive speech phenomena in two main elements of Parkinson’s disease, diVerent speech tasks. To compare the bradykinesia and rigidity, exert an influence on eVect of the motor state, the appearance of the motor speech system. The equivalents of repetitive speech phenomena was also hypokinesia or rigidity have been described as assessed in a subgroup of patients with monopitch, reduced stress, imprecisely pro- advanced Parkinson’s disease during the duced consonants, breathless voice, and on versus the oV state. monoloudness.1–356 Hyperkinesia has been Results—Speech repetitions emerged hypothesised to cause speech impairments on October 2, 2021 by guest. Protected copyright. mainly in two variants, one hyperfluent, such as voice harshness, excess loudness varia- University Clinic of formally resembling palilalia, and one tions, imprecise articulation, and disintegration Neurology, dysfluent, stuttering-like. Both forms 9 Anichstrasse 35, of respiratory processes. Iterative or repetitive A-6020 Innsbruck, were present in each patient producing speech phenomena are the least studied Austria repetitive speech phenomena. The repeti- features of the articulatory disorder in Parkin- Th Benke tive speech phenomena appeared in 15 son’s disease. Repetitive speech phenomena C Hohenstein patients (28.3 %), 13 of whom belonged to may be characterised broadly as a group of W Poewe the advanced disease group, indicating a variable speech iterations with immediately University College significant preponderance of repetitive successive repetitions of syllables, words, or London, UK speech phenomena in patients with a long phrases. Due to their heterogeneity, they have B Butterworth term, fluctuating disease course. Repeti- been labelled diVerently, as stuttering,10 speech tive speech phenomena appeared with iterations,11 or palilalia.12 13 With the exception Correspondence to: almost equal frequency during the on and of palilalia, which is a frequent sequel of Dr Thomas Benke 71415 [email protected] the oV state of patients with advanced postencephalitic Parkinson’s disease, the Parkinson’s disease. Their distribution phenomena are considered rare symptoms of Received 22 September 1999 among diVerent variants of speech was idiopathic Parkinson’s disease.4 However, only and in revised form 28 February 2000 disproportional, with eVort demanding few studies have undertaken a detailed search Accepted 12 April 2000 speech tasks producing a significantly for repetitive speech phenomena in Parkinson’s www.jnnp.com J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.69.3.319 on 1 September 2000. Downloaded from 320 Benke, Hohenstein, Poewe, et al disease. Koller10 studied six patients with memory, and constructional abilities17); a mul- parkinsonian symptoms who developed dysflu- tiple choice vocabulary test for the estimation ent, stuttering-like repetitions which were most of premorbid intelligence18; and two semantic pronounced in self formulated speech, aVected word list generation tasks (number of gener- initial phonemes more often, and were not ated animal names and supermarket items alleviated by levodopa therapy. Hertrich et al11 during a period of 60 seconds; perseverative described repetitive speech phenomena in a responses were subtracted from the total cognitively declined patient with Parkinson’s count). Short and long term retention of verbal disease appearing as predominantly monosyl- material was assessed using the story recall labic iterations occurring at all word positions. section of the Rivermead behavioural memory Ackermann et al4 noted a patient with idio- test.19 In all patients, motor ratings, speech pathic, late stage Parkinson’s disease with tasks, and neurobehavioural background tests on-oV fluctuations who developed palilalia were administered in the morning during the during peak dose hyperkinesia, pointing to a on state about 1 hour after drug administra- possible relation between the appearance of tion. repetitive speech phenomena and the drug induced on phase in long term Parkinson’s dis- PERCEPTUAL SPEECH EVALUATION ease. These studies have called attention to the It was the aim of this speech assessment to existence of repetitive speech phenomena in detect subjects with repetitive speech phenom- Parkinson’s disease and to possible influential ena, to evoke speech in diVerent categories of variables such as stage of disease, eVect of levo- natural language, and to characterise and dopa treatment, and cognitive background. count their repetitions on the basis of percep- However, due to the lack of data which have tual measurement. During the test procedure been derived systematically from a larger patients were seated in a quiet room. All patient population, the role of speech iterations patients received detailed instructions on how in Parkinson’s disease remains unclear. The to perform each test and were asked to speak present study was undertaken to describe the as slowly and distinctively as possible. Five characteristics of repetitive speech phenomena speech production tasks were tested. Patients in idiopathic Parkinson’s disease. More specifi- were asked to produce spontaneous speech cally, the aim was to describe the morphology during an extensive, semistructured interview of verbal iterations, to establish their preva- with questions regarding details of their lence in diVerent forms of the disease, and to disease, profession, family, and place of grow- evaluate their relation to neuropsychological ing up. Naming was evoked by having patients and clinical background data. describe the details of a complex scenic picture containing common objects. A reading test Patients and methods required reading aloud two short paragraphs PATIENTS of a prose text, both presented in large print on Fifty three patients with Parkinson’s disease an A4 sized sheet of paper; one paragraph were investigated in a prospective study contained normal words, whereas in the encompassing clinical, speech, and neuro- second passage 15% of all words had been psychological tasks. All patients were diag- changed to phonologically regular non-words. nosed according to UK Parkinson’s Disease Similarly, repetition of speech was tested using Society Brain Bank criteria.16 All patients had 15 words and four sentences, both of increas- two of the three cardinal signs (bradykinesia, ing length, taken from the Aachener http://jnnp.bmj.com/ rigidity, tremor) and showed no evidence of Aphasietest,20 and a corresponding section secondary parkinsonism due to antidopamin- using non-words and sentences containing ergic medication, or clinically relevant cer- neologisms. Automatic speech was assessed by ebrovascular disease. Additional criteria were asking patients to
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