Echolalia and Echopraxia are commonly recognized signs of catatonia noted in resources such as the DSM-5-TR [4] or the BFCRS [5] They are commonly referred to jointly as echo phenomenon. They are so named in that they are automatic and stimulus-bound in nature, providing a vocal or motoric copy of an environmental cue.

This straight-forward definition of echo phenomenon was noted in disorders as diverse as catatonia, schizophrenia, epilepsy, affective disorders, and neurodevelopmental disorders. Early analysts such as Stengel (1947) related this phenomenon to normal motor and speech development, and further conceptualized seemingly purposeless repetition of complex behaviors and speech topics as other forms of echo phenomenon [6]. Building upon this conceptualization, one contemporary review describes a multiplicity of echo phenomenon [7]. Among the included examples were echoplasia (repetitive mental or physical act of tracing the contours of a certain human or object, in the air, or on a given surface), echograpia (written repetition of usually verbal stimuli), and echolalioplasia (repetitive use of motor actions like sign language to echo verbal stimuli) [8,9,10]. These phenomena differ from echopraxia and echolalia in that the repetitious act is not in the same modality as the stimulus. This also demonstrates that echo phenomenon can include complex behaviors such as writing.

In addition to complex behaviors, there are further nuances of catatonic speech relevant to echo phenomenon. While describing catatonic speech disorders, Ungvari et al. [11] discuss the phenomenon of “Mental echolalia” (echoing only in mind) and “hallucinatory echolalia” (repeating one’s own hallucinations) as related phenomenon. This demonstrates that the patient’s echo response may be a mental phenomenon instead of an observable behavior, and the stimulus itself may be hallucinatory as in the case of hallucinatory echolalia. The latter bears resemblance to the patient described in this case report. However, the hallucinatory echolalia phenomenon represents a verbal output to what the patient experiences as auditory stimuli, and the patient in this case experienced auditory hallucinations as an output from written stimuli. Multiple reviews include further reports that the repeated response may even be temporally decoupled from the stimulus, as is the case in delayed echolalia [7, 11]. As with echoplasia, echographia, and echolalioplasia, these phenomena are stimulus bound and are recapitulatory in nature, though they are not necessarily in the same modality of the stimulus as is the case in echopraxia or echolalia.

This distinction has important implications for the detection and management of catatonia, as in the case of this patient. The patient’s own echo phenomenon suggested the continued presence of catatonic symptoms, which could be misinterpreted as signs of schizophrenia. This patient presented with manic symptoms in the setting of several months of psychotic symptoms, consistent with her historical diagnosis of schizoaffective disorder with catatonic features. This patient’s case is also notable for a varied and rapid presentation of catatonia that improved without the first-line therapy of benzodiazepines. However, catatonia is known to have a fluctuating natural history, and precedent exists for catatonia resolving with treatment of underlying affective illnesses [12]. Some resources, including the Maudsley prescribing guidelines, recommend trialing atypical antipsychotics if there is not a concern for neuroleptic malignant syndrome [13]. Despite this patient’s presentation with multiple catatonic signs and successful response to antipsychotics, it must be noted that catatonia is both under-recognized and under-treated [14], so subtle signs and symptoms of catatonia must be recognized to hasten diagnosis and treatment. The patient fortuitously responded well to initial treatment selection, though it is known that catatonic symptoms can worsen with antipsychotics.

In conclusion, if the premise of a diverse range of echo phenomenon is accepted, it stands to reason that there are as of yet undescribed echo phenomenon that can be observed in the diverse range of disorders that present with echo phenomenon such as catatonia, schizophrenia, autism spectrum disorder, and Tourette’s Syndrome [7]. These phenomenologically distinct signs and symptoms may evade clinical notice if diagnostic frameworks are limited to isolated presentations of phenomenon that can present in a multiplicity of unique ways. Frameworks for catatonia that can flexibly accommodate novel presentations of the syndrome may be of clinical utility in the future. Though the etiology of these phenomenon remains unclear, this case highlights the importance of careful dissection of the phenomenological experience of the patient, for catatonic symptoms can take varied and novel forms.