Perseveration: what it is, how it manifests itself and is treated

Features of treatment

There is no universally recommended treatment algorithm for perseveration. Therapy is carried out based on the use of a whole range of different approaches. One method should not be used as the only method of treatment. It is necessary to take new methods if the previous ones did not produce results. Roughly speaking, treatment is based on constant trial and error, which ultimately makes it possible to find the optimal method of influencing a person suffering from perseveration.

The presented methods of psychological influence can be applied alternately or sequentially:

• Expectation.
  It is the basis in psychotherapy for people suffering from perseveration. The point is to wait for changes in the nature of the deviations that have arisen against the background of the use of various methods of influence. That is, the waiting strategy is used in conjunction with any other method, which we will discuss below. If no changes occur, switch to other psychological methods of influence, expect results and act according to the circumstances.
• Prevention.
  It is not uncommon for two types of perseveration (motor and intellectual) to occur together. This makes it possible to prevent such changes in time. The essence of the technique is based on the exclusion of physical manifestations that people most often talk about.
• Redirection.
  This is a psychological technique based on a sharp change in ongoing actions or current thoughts. That is, when communicating with a patient, you can suddenly change the topic of conversation or move from one physical exercise or movement to another.
• Limitation.
  The method is aimed at consistently reducing a person’s attachment. This is achieved by limiting repetitive actions. A simple but clear example is to limit the amount of time a person is allowed to sit at a computer.
• Abrupt cessation.
  This is a method of actively getting rid of perseverative attachment. This method is based on the effect of introducing the patient into a state of shock. This can be achieved through harsh and loud phrases, or by visualizing how harmful the patient’s obsessive thoughts or movements or actions can be.
• Ignoring.
  The method involves completely ignoring the manifestations of the disorder in a person. This approach works best if the disorders were caused by attention deficit. If a person does not see the point in what he is doing, since there is no effect, he will soon stop repeating obsessive actions or phrases.
• Understanding.
  Another relevant strategy with which the psychologist recognizes the patient’s train of thought in case of deviations or in the absence of them. This approach often allows a person to independently understand his thoughts and actions.

Perseveration is a fairly common disorder that can be caused by various reasons.

When perseveration occurs, it is important to choose a competent treatment strategy. Medication is not used in this case.

Speech stereotypies, also known as speech iterations, verbal tics, are reflexive, meaningless and emotionally indifferent repetitions of sounds, syllables, words and entire phrases in the patient’s speech.

The patient’s speech can be either on his own initiative or provoked by questions from people around him.

Speech disorders. Speech iterations

This part of the chapter is, as it were, complementary to the sections of the book in which many speech disorders are described. A systematic presentation of the psychopathology of speech (different forms of speech and at different stages of speech development in representatives of different language systems) is currently difficult to imagine due to insufficient knowledge of this problem. Here we will limit ourselves to describing or just mentioning some speech disorders. Let us note one important circumstance: speech disorders will be presented, and not thinking disorders, although it seems obvious that both are interrelated. However, this relationship needs to be studied, and it is likely that it may vary. For example, it is known that fragmented thinking is manifested by fragmented oral speech. However, it should be borne in mind that this implies a disconnection of verbal-logical thinking.

It is unclear what the situation is with other forms of thinking. It may very well be that some of them are damaged to a lesser extent or, which also cannot be excluded a priori, are intact. It is completely unclear in what state inner speech is in such patients. The same applies to writing. Oral speech may be in a state of disarray, but this does not mean that written speech suffers equally or in the same way and vice versa. Therefore, the text does not include characteristics of speech that directly indicate a particular disorder of thinking, for example, incoherent, detailed speech, etc. We also note that in assessing disorders identified through questioning, both deviations in thinking and speech disorders should be taken into account. Patients' self-descriptions are by no means always identical to genuine painful experiences.

Speech iterations (from the Latin iterativus - often repeated) or speech stereotypies, verbal tics - involuntary, meaningless and emotionally indifferent repetitions, often multiple, of phrases, words, syllables, individual sounds of the patient’s own oral speech, both spontaneous and provoked by questions sides. The disorder includes palilalia, verbigeration, perseveration, reflexive expressions, and writing such as paligraphy (Crichley, 1974).

Palilalia (Brissaud, 1899; Souques, 1908; Pick, 1921) is the patient repeating two or more times a phrase, some part of it, a word, a syllable from the end of a fragment of speech he has just spoken aloud. The volume of repetition usually does not exceed that of the prototype, the pace of repetition may gradually accelerate and the volume may decrease, and words may be partially swallowed. So, after answering the question about today’s date (answer: I don’t know, there is no date), the patient repeats the answer six times in a row almost without interruption. Another patient correctly names the days of the week, and then, without stopping, at the same pace and with the same intonation, repeats what was said two more times. Palilalia in relation to one or more phrases is also designated as a symptom of a gramophone record (Mayer-Gross, 1931), a symptom of chimes, and standing figures of speech. This symptom is typical of Pick's disease; it also occurs in striatal pathology, in the structure of postencephalitic parkinsonism, pseudobulbar syndrome.

Palilalia occurs in relation to various forms of speech, both intellectual and emotional (exclamations, shouts, swearing, etc.). It is also observed in the structure of verbal hallucinations. As a rule, it does not concern automated speech patterns pronounced mechanically. The number of repetitions can reach 20 or more. Repetitions at the end are sometimes made silent - aphonic palilalia. Palilalia is observed with striopallidal pathology of various origins (vascular, inflammatory, atrophic), as well as with catatonia. Palilogy should be distinguished from palilalia - an oratorical technique in the form of repetition of fragments of speech in order to emphasize their special meaning. Sometimes palilogy occurs among speakers when they are excited and lose the thread of their statements.

Verbigeration or perseveratory logorrhea (from the Latin verbum - word, gerere - to create) - “stringing” words that are similar in sound but different in meaning, stretching and distorting words, pronouncing meaningless combinations of sounds and words (Kahlbaum, 1874). So, the patient loudly shouts the same phrase for several hours: “The sun doesn’t play with meat.” Another says, as if rhyming sound combinations, the following: “Ah, tah, chwah, brah, tuh, zhukh...”. Verbigeration can be heard in verbal hallucinations. Usually occurs in patients with catatonic manifestations of schizophrenia.

Anxious verbigeration is the repeated repetition of expressions of despair in patients with panic, anxiety and anxious depression at the height of the disorder - raptus (excitation of motor, expressive and speech). So, the patients loudly lament: “I’m dying, save me... do something... my God, what to do now!”

Perseveration (from Latin persevero - stubbornly hold on, continue) - getting stuck in verbal responses to questions (Neisser, 1894). Thus, having given his last name to the first question, the patient continues to give his last name several times during subsequent questions. Perseverations can occur in written speech, and also arise in the motor sphere: having written a word or phrase, the patient continues to write the same thing instead of subsequent ones; Having performed an action, the patient repeats the first one instead of several new ones. Speech perseverations are observed in sensory aphasia, stunned consciousness, motor perseverations are observed in atrophic processes, catatonia. Along with those mentioned, some authors also talk about the existence of sensory and emotional perseverations.

Recurrent expressions (Jackson, 1864) are speech stereotypies in patients with severe sensory aphasia, when speech is limited to one word or one phrase, inappropriately repeated in a variety of situations. Thus, a patient after a traumatic brain injury invariably uttered the same word to different questions or in different situations: “Help!” Jackson assumed that such words and expressions were associated with some kind of thought at the moment of the disaster; the patient seemed to want to express it at that very moment, but did not have time.

Paligraphy is a written version of speech iteration. The patient, having started to write, writes one word, the same phrase, sometimes a completely meaningless combination of syllables or letters. Thus, the patient spontaneously wrote four pages with the following expression:

“Fe-te-te-re-fe-te-te.” In exactly the same way, the same pattern can be repeated, often completely meaningless.

Logoclony (logo + from the Greek klonos - random movement) is the rhythmic repetition of syllables in oral and written speech. First described in progressive paralysis (Kraepelin, 1904). Logoclony, which extends from the initial syllables of a word to the intermediate syllables and then to the final syllables, is considered a characteristic symptom of Alzheimer's disease. It is also observed in Pick's disease and some forms of encephalitis.

Back to contents

Speech stereotypies and psychoneurological diseases

The causes of speech stereotypies often lie in the development of neurological and psychological diseases.

Causes of perseverations

Experts believe that the cause of perseveration is damage to the lower parts of the premotor nuclei of the cortex of the left hemisphere in right-handers, and the right hemisphere in left-handers.

The most common cause of perseveration is considered to be neurological diseases resulting from physical damage to the brain. In this case, it becomes impossible to switch between different activities, changing the train of thought and the order of actions when performing various tasks.

With the neurological nature of the disease, the causes of perseveration are:

1. , in which the lateral orbitofrontal areas of the cortex and its prefrontal convexities are affected.
2. - the appearance of disturbances in speech formed at the previous stage of life. These disorders arise due to physical damage to the speech centers, as a result of traumatic brain injury.
3. Pathologies related to the area of ​​the frontal lobes of the cerebral cortex
   .

Psychiatry and psychology classify perseveration as a symptom of various phobias and anxiety syndromes. The course of this speech stereotypy in the psychological and psychiatric direction can be caused by:

• obsessiveness and selectivity of individual interests, which is most often found in people with autistic disorders;
• lack of attention with hyperactivity, while stereotypy arises as a defense mechanism to attract attention to oneself;
• a steady desire to learn and experience new things can lead to fixation on one conclusion or activity;
• perseveration is often one of the symptoms.

Perseveration should not be confused with obsessive-compulsive disorder, human habits, and sclerotic changes in memory.

Perseverations are more often observed in patients with dementia (), which is caused by, as well as with age-related atrophic processes in the brain. The patient’s intellect is impaired, and he cannot understand the question being asked and, instead of a logical answer, repeats previously used phrases.

What provokes the development of verbigeration?

With verbigeration there is no connection with certain neuropsychic conditions. One of the features of verbigeration is that the patient pronounces words without showing emotion. As a rule, verbal repetitions are accompanied by active facial expressions and motor disturbances.

Most often, these verbal iterations occur in patients with catatonic schizophrenia.

Causes of standing revolutions, palilalia and echolalia

The appearance of standing phrases in speech signals a decrease in intelligence and empty thinking. They often appear with a disease such as epileptic dementia. Also, one of the diseases in which standing turns are characteristic is, as well as other atrophic diseases of the brain.

Palilalia is a typical manifestation of Pick's disease. It also often accompanies diseases such as striatal pathology, striopallidal pathology (atrophic, inflammatory, vascular), postencephalic, and schizophrenia.

The occurrence of echolalia is often associated with damage to the frontal lobes of the brain. If the patient has symptoms such as hallucinations, lack of coordination, and forgetfulness, it is necessary to seek advice from a specialist. If brain damage is not diagnosed, then the causes of echolalia may be schizophrenia, autism, or Tourette's syndrome.

Causes and possible diseases

In the form of compulsive rumination, persistence occurs mainly in depressive syndrome or affective disorder:

Depressive syndrome is a state of depression and decreased activity. It can develop, for example, under stress and adjustment disorders or in the context of other diseases such as heart failure or high blood pressure.

Affective (bipolar) disorder is characterized by recurrence of depressive and manic phases.

Often persistence is also observed in the context of dementia development. The term dementia refers to a continuous decline in mental abilities.

Perseveration may also be present in patients with obsessive-compulsive disorder. This mental disorder manifests itself in the form of obsessive thoughts and compulsive actions.

Diseases with this symptom:

• dementia
• bipolar disorder
• depression
• schizophrenia
• traumatic brain injury
• depersonalization
• autism
• obsessive-compulsive disorder
• mania
• alzheimer

Establishing diagnosis

Diagnosis of speech stereotypies involves comprehensive testing. The patient is asked to undergo special testing or answer simple questions (implying “yes” or “no” answers), repeat similar-sounding sounds or sound combinations.

The patient is also asked to name the objects that are in the room, name the days of the week, explain the meaning of the words, and retell the text.

When examining a patient, it is very important to determine whether he understands speech addressed to him. If there is a suspicion of mild forms of speech disorders, the speech pathologist uses other more complex diagnostic methods

To diagnose speech stereotypies, a technique is used that includes a series of separate tests. The patient is asked to write words in normal and reverse order, write words and phrases in upper and lower case letters, read text in forward and reverse order, write numbers in normal and reverse order, and perform multiplication. When making toasts, the doctor assesses the number of correct and incorrect answers per minute.

Reasons for the manifestation of perseveration

There are neuropathological, psychopathological and psychological reasons for the development of perseveration.

Repetition of the same phrase, caused by the development of perseveration, can occur against the background of neuropathological reasons. These most often include:

• Traumatic brain injuries that damage the lateral region of the orbitofrontal cortex. Or it is due to the physical types of damage to the frontal convexities.
• For aphasia. Perseveration often develops against the background of aphasia. It is a condition characterized by pathological deviations of previously formed human speech. Similar changes occur in the event of physical damage to the centers in the cerebral cortex responsible for speech. They can be caused by trauma, tumors or other types of influences.
• Transferred local pathologies in the frontal lobe of the brain. These may be similar pathologies, as is the case with aphasia.

Psychiatrists, as well as psychologists, call perseveration deviations of a psychological type that occur against the background of dysfunctions occurring in the human body. Often, perseveration acts as an additional disorder and is an obvious sign of the formation of a complex phobia or other syndrome in a person.

If we talk about the psychopathological and psychological reasons for the development of perseveration, there are several main ones:

Tendency to increased and obsessive selectivity of interests. Most often this manifests itself in people characterized by autistic disorders. The desire to constantly learn and learn, to learn something new. It occurs mainly in gifted people. But the main problem is that that person may become fixated on certain judgments or his activities. The existing line between perseveration and such a concept as perseverance is extremely insignificant and blurred. Therefore, with an excessive desire to develop and improve oneself, serious problems can develop. Feeling of lack of attention. Occurs in hyperactive people

The development of perseverative inclinations in them is explained by an attempt to attract increased attention to themselves or their activities. Obsession with ideas. Against the background of obsession, a person can constantly repeat the same physical actions caused by obsession, that is, obsession with thoughts.

The simplest, but very understandable example of obsession is the desire of a person to constantly keep his hands clean and wash them regularly. A person explains this by saying that he is afraid of contracting terrible infections, but such a habit can develop into a pathological obsession, which is called perseveration.

It is important to be able to distinguish when one person simply has strange habits in the form of constant hand washing, or whether it is obsessive-compulsive disorder. It is also not uncommon for repetitions of the same actions or phrases to be caused by a memory disorder, and not by perseveration

Manifestations

Based on the nature of perseveration, the following types of its manifestation are distinguished:

• Perseveration of thinking or intellectual manifestations. It is distinguished by the “settling” in the human creation of certain thoughts or its ideas, manifested in the process of verbal communication. A perseverative phrase can often be used by a person when answering questions to which it has absolutely nothing to do. Also, a person with perseveration can pronounce such phrases out loud to himself. A characteristic manifestation of this type of perseveration is constant attempts to return to the topic of conversation, which has long been stopped talking about or the issue in it has been resolved.
• Motor type of perseveration. Such a manifestation as motor perseveration is directly related to a physical disorder in the premotor nucleus of the brain or subcortical motor layers. This is a type of perseveration that manifests itself in the form of repeating physical actions repeatedly. This can be either the simplest movement or a whole complex of different body movements. Moreover, they are always repeated equally and clearly, as if according to a given algorithm.
• Speech perseveration. It is classified as a separate subtype of the motor type perseveration described above. These motor perseverations are characterized by constant repetition of the same words or entire phrases. Repetition can manifest itself in oral and written form. This deviation is associated with lesions of the lower part of the premotor nucleus of the human cortex in the left or right hemisphere. Moreover, if a person is left-handed, then we are talking about damage to the right hemisphere, and if a person is right-handed, then, accordingly, to the left hemisphere of the brain.

Types of perseveration

Based on the nature of the disorder under consideration, the following variations are distinguished, as already listed above: perseveration of thinking, perseveration of speech and motor perseveration.

The first type of deviation described is characterized by the individual’s “fixation” on a certain thought or idea that arises during communicative verbal interaction. A perseverative phrase can often be used by an individual to answer the above questions, without having anything to do with the meaning of the interrogative statement. Jamming on one representation is expressed in stable reproduction of a certain word or phrase. More often this is the correct response to the first interrogative sentence. The patient gives a primary answer to further questions. Characteristic manifestations of perseveration of thinking are considered to be sustained efforts to return to the subject of conversation, which has not been discussed for a long time.

A similar condition is inherent in atrophic processes occurring in the brain (Alzheimer's or Pick's disease). It can also be detected in traumatic psychosis and vascular disorders.

Motor perseveration is manifested by repeated repetition of physical operations, both simple manipulations and a whole set of various body movements. At the same time, perseverative movements are always reproduced clearly and equally, as if according to an established algorithm. There are elementary, systemic and speech motor perseverations.

The elementary form of the described deviation is expressed in repeated reproduction of individual details of movement and arises as a result of damage to the cerebral cortex and underlying subcortical elements.

The systemic type of perseveration is found in the repeated reproduction of entire complexes of movements. It occurs due to damage to the prefrontal segments of the cerebral cortex.

The speech type of the pathology in question is manifested by repeated reproduction of a word, phoneme or phrase (in writing or in oral conversation). Occurs in aphasia due to damage to the lower segments of the premotor zone. Moreover, in left-handers, this deviation occurs if the right side is affected, and in right-handed individuals - when the left segment of the brain is damaged, respectively. In other words, the type of perseveration under consideration arises as a result of damage to the dominant hemisphere.

Even in the presence of partial aphasic deviations, patients also do not notice differences in the reproduction, writing or reading of syllables or words that are similar in pronunciation (for example, “ba-pa”, “sa-za”, “cathedral-fence”), they confuse letters that sound similar .

Perseveration of speech is characterized by persistent repetition of words, statements, phrases in written or oral speech.

In the mind of a subject suffering from speech perseveration, it is as if a thought or word is “stuck”, which he repeats repeatedly and monotonously during communicative interaction with interlocutors. In this case, the reproduced phrase or word has no relation to the subject of the conversation. The patient's speech is characterized by monotony.