Repetitive Speech Phenomena in Parkinson's Disease

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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 neuropsychological 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

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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 name the months of the the absence of dementia, major depression, year. Spontaneous speech, naming, reading, aphasia, previous alcohol or drug misuse, brain and repetition of text containing neologisms trauma, or severe hearing loss. Subjects were were considered forms of eVortful speech pro- inpatients and outpatients of the Clinic of duction compared with automatic speech, on October 2, 2021 by guest. Protected copyright. Neurology, Innsbruck who gave their verbal reading, and repetition of normal text which informed consent to participate in the study. were judged semiautomatic speech produc- Patients were divided into groups according to tion. To establish the eVect of on and oV states the stability of their drug response. Twenty on the appearance of repetitive speech phe- nine patients who had a stable response to nomena, seven patients of the advanced levodopa were compared with 24 patients who Parkinson’s disease group who had marked had reached a more advanced disease stage motor fluctuations were tested twice, once with unstable drug response, including fre- during the on and once in an oV phase using quent motor fluctuations, unpredictable wear- parallel but equivalent test materials for the ing oV phenomena, and dyskinesia. Degree of assessment of each speech modality. overall impairment due to Parkinson’s disease Considerable overlaps exist between the was rated during on states on the Hoehn and labelling of various forms of repetitive verbal Yahr scale. A neuropsychological screening behaviour such as iterations, perseverations, procedure was performed to exclude demented palilalia, acquired neurogenic stuttering,21 patients and to compare both patient groups recurring utterances, and stereotypies (for for their basic cognitive abilities. The test definitions and a review of repetitive verbal battery included the mini mental state exam- behaviour see Wallesch22). For the purpose of ination (tapping orientation, speech, attention, this study, the definition of repetitive speech

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Table 1 Demographics, clinical characteristics, and neuropsychological test results advanced Parkinson’s disease group, disease duration was significantly longer, and the aPD (n=24) sPD (n=29) p Value amount of disease severity as measured by the Age (y) 65 (41–78) 70 (45–84) NS Hoehn and Yahr scale was significantly greater. Years of education 8 (4–12) 8 (6–12) NS Duration of disease (years) 11 (3–18) 5 (2–17) 0.00 Mean scores on general mental functioning Hoehn and Yahr stage 3 (1–5) 3 (1–3.5) 0.01 (MMSE) and memory were above the cut oV for Side of predominant motor impairment (% right:% left) 56.5:43.5 50:50 NS an impairment indicating dementia (table 1). Sex distribution (% female:male) 25:75 38:62 NS MMSE 26 (15–30) 28 (21–30) NS Premorbid IQ 100.5 (69–136) 100.5 (85–134) NS FORMS OF REPETITIVE SPEECH PHENOMENA IN RBMT, immediate 7 (1–22) 7 (1–14) NS PARKINSON’S DISEASE RBMT, long 5 (0–18) 6 (0–11) NS WLG 17.5 (4–34) 20.5 (5–33) NS An analysis and comparison of the transcribed iterations indicated that they could be grouped Values are medians (range); p values by Student’s t test for independent samples (demographics); ÷2 analysis (sex and side distributions), and Mann-Whitney U test (neuropsychological tasks); in two types. repetitive speech phenomena type aPD=advanced Parkinson’s disease with motor fluctuations; sPD=stable, non-fluctuating Parkin- 1, formally resembling palilalia14 23 were hyper- son’s disease; MMSE= mini mental state examination; premorbid IQ=premorbid intelligence quotient; RBMT immediate=score of immediate story recall of the Rivermead behavioural fluent repetitions uttered fast and with increas- memory test; RBMT long=score of long delay story recall of the RBMT; WLG=sum of both word ing speech rate; due to their often poor articu- list generation tasks. lation and decreasing loudness they became phenomena was acoustically identifiable itera- increasingly blurred or murmured. By contrast, tions of phonemes, syllables, words, or utter- repetitive speech phenomena type 2 were ances. They were categorised using four dysfluent, prolonged, stuttering-like iterations distinctive criteria: fluency (fluent v non- which were relatively well articulated at a con- fluent), speech rate (accelerando v constant stant rate and loudness. As both types of speech speech rate), articulation (intact v poor articu- repetitions were so phenomenologically dis- lation), and loudness (constant v inconstant tinct, it was thought that there was no need to speech volume). Each patient was screened for establish interrater reliabilities. A small per- the appearance of repetitive speech phenom- centage of repetitive speech phenomena did ena. The speech of patients with repetitive not fit into one of both categories or was speech phenomena was recorded on audiotape impossible to diVerentiate according to the or videotape and entirely transcribed and ana- above described criteria (type 3). Example lysed word by word. Due to the limited distin- utterances of the two most common types are guishing quality of a perceptual speech analy- summarised in table 2. sis, and the often reduced articulatory precision and low volume in Parkinsonian dysarthrophonia, it was often impossible to PREVALENCE OF REPETITIVE SPEECH PHENOMENA identify the number of iterated speech seg- IN PARKINSON’S DISEASE ments within a single repetitive speech phe- From a total of 53 patients with Parkinson’s nomenon. Therefore, each phenomenon was disease, 15 (28.3%) displayed repetitive speech counted as a single entity, irrespectively of the phenomena. Of those, 13 belonged to the number of its repeated speech elements (sylla- advanced Parkinson’s disease and two to the bles, words, utterances, etc). The number of stable Parkinson’s disease sample. Thus, the phenomena across speech tasks were counted prevalence of repetitive speech phenomena in from the written speech protocol and expressed patients with advanced Parkinson’s disease was http://jnnp.bmj.com/ as percentage of the patient’s total word 54.3%, whereas in the stable Parkinson’s sample. disease sample it was only 6.9%. This indicates a significant preponderance of repetitive Results speech phenomena in patients with long term DEMOGRAPHIC, CLINICAL, AND disease and fluctuating motor response to levo- NEUROPSYCHOLOGICAL VARIABLES dopa (p=0.007, Fisher’s exact test). Within the

As groups, patients with advanced Parkinson’s advanced Parkinson’s disease group, the 13 on October 2, 2021 by guest. Protected copyright. disease or stable Parkinson’s disease were similar subjects producing repetitive speech phenom- in demographical variables, their general mental ena did not diVer from the rest in demograph- state, and performance on the verbal memory ics, duration of disease, and motor or cognitive and the two semantic ﬂuency tasks. In the performance.

Table 2 Characteristics of two repetitive speech phenomena in Parkinson’s disease

Fluency Speech rate Other speech characteristics Example utterance

Type 1 (hyperfluent) Fluent rushes of speech Increasing (accelerando), Often poorly articulated, “meinmeinmeine parkinsonkrankheit“ hastening occasionally decreasing “kraftfahrscheinzeugzeug“ loudness (decrescendo) “mitmitmit medikamenten begobegonnen“ “unddieunddie tiere“ “nichtnicht mehr agieren, nichtnichtnicht reagieren“ “an die tiere verVVfverfüttert“ “ich bbbbin dann nach ... gegangen“ Type 2 (dysfluent) Non-fluent, clonic, Constant Well articulated, loudness “von kopf bis fuâ u-u-u-u-un-untersucht“ stuttering-like, staccato, constant “hat schlecht a-a-a-a-an-angefangen“ short intervals between “wir ar-wir-arbeiten viel“ iterated speech segments “es war sein schwa-sein-schwager“ “ein auto-autoreifen“ “ohne tab-ohne-tabletten“

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10 DISTRIBUTION OF REPETITIVE SPEECH Effortful PHENOMENA AMONG SPEECH TASKS 9 Semiautomatic There was uneven distribution of repetitive 8 0.013 speech phenomena among the tested speech tasks (ﬁgure). Contrary to a previous case 7 description24 where repetitive speech phenom- 6 ena were strictly linked to a task of speech rep- 5 etition, in this study picture naming and spon- 0.046 taneous speech generated the highest 4 percentage of repetitive speech phenomena, 3 whereas semiautomatic speech yielded only

% RSP/speech sample one in the whole sample of repetitions. 2 Furthermore, reading and repeating non- 1 words produced significantly more repetitive speech phenomena than reading and repeating 0 Spont Pict Read Repe Auto normal text (p=0.013 and 0.046, respectively). Percentage of repetitive speech phenomena as found in It also seems noteworthy that a relatively large diVerent categories of eVortful and semiautomatic speech. number (18%) of all repetitive speech phenom- Spont=spontaneous speech, Pict=naming in picture ena were provoked by word finding diYculties description task, Read=reading, Repe=repetition, during spontaneous speech or during confron- Auto=automatic speech. p Values refer to paired samples t test. tation naming in the picture description task. Only 8% of all situations with word finding dif- AMOUNT AND TYPES OF REPETITIVE SPEECH ficulties were not coupled with repetitive PHENOMENA IN PARKINSON’S DISEASE speech phenomena. The total recorded speech sample of patients displaying repetitive speech phenomena was REPETITIVE SPEECH PHENOMENA DURING THE ON 8117 words; 470 repetitive speech phenomena VERSUS THE OFF STATE were counted in this sample. The counts of To evaluate the eVect of the on and oV states on repetitive speech phenomena types 1, 2, and 3 the appearance of repetitive speech phenom- were 174, 227, and 69, respectively. Thus, type ena, seven patients with advanced Parkinson’s 1 constituted 37%, type 2 48.3%, and type 3 disease who agreed to participate in this study only 14.7% of all iterations. Within the group were assessed during both states. The order of of patients producing repetitive speech phe- examinations in the on and oV state was coun- nomena there was little variation of this distri- terbalanced in this subgroup. Parallel test bution pattern. Each patient with repetitive materials were used in both states. Table 3 speech phenomena produced all three types. shows a direct comparison of the appearance of The percentages of types 1, 2, and 3 were 2.14 repetitive speech phenomena in both func- %, 2.79%, and 0.85 % of the total word count. tional states. As evident from this table, the Patients with Parkinson’s disease iterated pho- amount of words spoken in both states was nemes, syllables, words, and utterances, but about the same. There was a tendency for most often single syllables and words. The repetitive speech phenomena to appear more number of acoustically identifiable iterations often in the on state. However, there was no ranged from one to six; most repetitive speech significant diVerence between the number of phenomena had two to three iterations. Type 1 repetitive speech phenomena in both states. http://jnnp.bmj.com/ and type 2 were most often located at word Also, types 1, 2, and 3 had similar prevalences beginnings, but were also found amidst and at and a similar distribution pattern in both motor the end of words and phrases. Occasional states. Similarly, a detailed comparison of indi- blends of type 1 and type 2 were also found (for vidual speech tasks (spontaneous speech, nam- example, “ich habe eine schwe-eineine-schwester” ing, reading, repetition, and automatic speech) “nachher wa-wa-war mein vater ver-ver-vermiât yielded no significant diVerence in individual im krieg”. The two patients with stable Parkin- numbers or profiles of produced repetitive son’s disease who iterated speech had a similar speech phenomena in the on versus the oV on October 2, 2021 by guest. Protected copyright. amount and proportion of repetitive speech state. The only qualitative diVerence between phenomena types as found in patients with both states were poorer articulation and advanced Parkinson’s disease. decreased volume of repetitive speech phe- Table 3 Comparison of RSP during on and oV state in seven patients with advanced nomena in the oV state in general. Parkinson’s disease Discussion On state OV state Since Pick’s12 and Merzbach’s25 original obser- Word count: vations in patients with vascular lesions, it is Sum 4932 4615 well recognised that lesions of the basal ganglia Median 687 660 Range 413–865 470–1080 may be associated with repetitive speech nRSP % RSP Prop RSP n RSP % RSP Prop RSP phenomena. Later descriptions have focused RSP Type 1 69 1.39 34 % 58 1.26 32.2 % on the appearance of stuttering in Parkinson’s RSP Type 2 93 1.88 45.8 % 84 1.81 46.4 % disease,7810111424 progressive supranuclear RSP Type 3 41 0.83 20.2 % 39 0.84 21.4 % 26 27 28 RSP Type 1+2+3 203 4.10 100 % 181 3.89 100 % palsy, Tourette’s syndrome, or in Wilson’s disease. In an attempt to learn more about Word count=number of words recorded across all speech tasks. nRSP=absolute number of RSP; repetitive speech behaviour in Parkinson’s dis- % RSP=percentage of RSP per total word count; Prop RSP=proportion of RSP per total number. There were no significant diVerences of word or RSP counts between the two states ease, we have analysed repetitive speech (Mann-Whitney U test). phenomena in a cohort of carefully selected,

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non-demented patients with idiopathic Parkin- categories of speech such as fluency, rate, son’s disease. The principal findings show that articulation, and loudness were used to obtain there are two clearly discernible forms of the a classification of the phenomena. With the phenomena in Parkinson’s disease; that repeti- exception of amorphous (type 3) speech tions of speech are almost exclusively present in repetitions, which accounted only for a minor a subgroup of patients with Parkinson’s disease percentage of speech iterations, two main with advanced disease stage and unstable patterns could be diVerentiated (table 1). Type motor response; furthermore, that repetitive 1 comprised hyperfluent, poorly articulated speech phenomena appear both in the on and iterations, mostly uttered with increasing the oV state; and finally that they are not speech rate and decreasing loudness, closely necessarily coupled with dementia. resembling the classic description of With the exception of two patients with palilalia.8 14 37–38 These iterations have previ- stable Parkinson’s disease, repetitive speech ously been described in postencephalitic phenomena in this study were only found in parkinsonism,15 39 as well as in many neuropsy- patients with advanced, long term Parkinson’s chiatric disorders.24 25 28 29 32 33 38 40 41 Type 2 was disease. In this subgroup, about half of all a non-fluent, well articulated iteration, pro- patients produced speech iterations. Even if the nounced with constant loudness and rate. This chosen selection criteria do not allow us to was produced in a staccato-like manner and establish their general prevalence, the numbers resembled earlier descriptions of stuttering in of iterations found disproves the notion that Parkinson’s disease.10 11 Similar to an earlier repetitive speech phenomena are rare in report,11 iterations occurred at all word posi- Parkinson’s disease,4929 as in our study they tions. In this study, the two main types of appeared in 28% of the total Parkinson’s repetitive speech phenomena, type 1 and type disease sample, and the amount of iterated 2, constituted 37% and 48.3% of all iterations, speech was almost 6% of the elicited total word respectively; thus the proportion was roughly count. Despite this strong association with 1:1.3. This distribution remained largely con- unstable, fluctuating Parkinson’s disease, it stant among diVerent speech tasks. Both types seems notable that iterations in patients with appeared in each patient producing speech advanced Parkinson’s disease were generated iterations. Occasional blends of type 1 and type both during the on and the oV state. Further- 2 were also found. With the reservation that a more, they emerged in both motor states with purely perceptual analysis of parkinsonian dys- similar forms and distribution patterns among arthrophonia can only provide a quantitative speech tasks. These findings do not support estimation of these variables, both repetitive previous assumptions that repetitive speech speech phenomena types did not diVer in the phenomena can be explained as symptoms of iterated speech material—that is, their number levodopa induced hyperkinesia.24 29 However, of iterations, the speech segment being iterated in the light of the small sample size the results (syllable, word, or sentence), as well as the of this study must be interpreted with caution locus of reiteration within utterances (begin, and will need further, more detailed replica- medial, end). Thus, both types of repetitive tion. The coupling between repetitive speech speech phenomena diVer in their acoustic phenomena and advanced Parkinson’s disease properties such as fluency, rate, loudness or suggests that the events during the progression articulatory control, but not remarkably for the of the disease—namely, neuron degeneration iterated speech substrate, such as the number and transmitter disturbances30 may also be the of repeated elements, the task, or the reitera- http://jnnp.bmj.com/ pathophysiological mechanisms responsible for tion type (syllable, word, or utterance). Also, the generation of the speech iterations. each type was present in each patient, indicat- As it is well known that repetitive speech ing that the disease may bring forth two, or phenomena appear in patients with possibly even several diVerent forms of repeti- dementia,15 24 29 31–33 we were particularly inter- tive speech, without creating subgroups of spe- ested in investigating the cognitive status of our cificity among patients. These findings confirm patients with Parkinson’s disease and repetitive the coexistence of hyperfluency and dysfluency verbal behaviour. Impairments of orientation, in one disease, as well as the variability of on October 2, 2021 by guest. Protected copyright. memory, and verbal associative functions are speech rate, articulatory clearness, and loud- among the most prominent findings of a devel- ness. They are in line with other findings oping dementia in patients with Parkinson’s pointing to the variability of some speech vari- disease.34–36 In the present study, neuropsycho- ables in Parkinson’s disease,468 which may logical background tests of patients with stable appear as a continuum of symptoms rather Parkinson’s disease or advanced Parkinson’s than a uniform profile of speech. disease showed normal and equivalent group At present, the origin of repetitive speech means on tasks tapping general mental abilities phenomena in Parkinson’s disease is unclear. and verbal memory; scores on a word list gen- As the results of this study are based on a eration task were in the lower normal range. It purely perceptual analysis of parkinsonian can therefore be assumed that repetitive speech speech and lack other, more objective—for phenomena may also be found in association example, kinematic observations— they can with an average cognitive status as assessed by only bring forward two hypotheses regarding standard tests of memory and orientation, and generation of the iterations. The motor hypoth- that dementia may not be a prerequisite for the esis holds that repetitive speech phenomena are iterations the result of a malfunction at the level of motor Based on the morphological characteristic of speech, probably resulting from a disintegra- repetitive speech phenomena, simple rating tion of subcorticocortical interplay, whereby

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the basal ganglia stimulate speech activity in nia in Parkinson’s disease8 may be both a disor- the cortex in an uncontrolled manner29; der of speech and of language. alternatively, defective execution of prepro- grammed motor sequences may result in an We are grateful for the comments and suggestions of Hermann impairment of the duration and fluency of Ackermann and two anonymous reviewers who provided help- 42–46 ful insights for the preparation of this paper. Parts of this paper speech events. More specifically, repetitive were presented as a poster at the 9th TENNET Conference, speech phenomena may be speech equivalents Montreal, 1998. of the “freezing” or “motor block” phenom- 1 Darley FL, Aronson AE, Brown JR. DiVerential diagnostic enon, a sudden and short lasting break in patterns of dysarthria. J Speech Hear Res 1969;12:246–69. motion as well as inhibition in executing a 2 Darley FL, Aronson AE, Brown JR. Clusters of deviant speech dimensions in the dysarthrias. 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