What is Echopraxia?

It can be natural, normal human behaviour to imitate other people’s gestures or actions. After all, this is how babies and children learn social interaction. However, when this happens involuntarily and often, you could be looking at something called echopraxia.

Echopraxia, in this way, is similar to the much more well-known echolalia – especially when you look at co-occurring conditions like autism spectrum disorder. It’s believed that around 75% of autistic people experience echolalia in some form but there are no statistics available for echopraxia.

This article will tell you all about echopraxia, including what it looks like and how it is managed.

What is echopraxia?

Echopraxia (which might also be called echokinesis or echomotism) is an involuntary imitation or repetition of someone else’s actions. While echolalia is the involuntary repetition of language and sounds, echopraxia is the same but with actions. The word itself comes from Ancient Greek.

Echopraxia is an echophenomenon, which is pathological repetitions of actions that are automatic and undeliberate. The condition is recognised particularly in Tourette syndrome as a tic but it can also be seen in aphasia, startle reflex disorders like latah, catatonia, schizophrenia and autism spectrum disorders.

The involuntary mirroring of another’s actions might be as subtle as picking up an object or it could be a violent act like hitting. A person with echopraxia could imitate someone’s walking style, body language, or the way they fidget. Essentially, it’s categorised by the fact it is both repetitive and involuntary.

Echopraxia can often seem deliberate because it is a highly complex tic that requires the imitation of lots of different behaviours at once. Since it’s about repeating someone else’s natural behaviours, it might go unnoticed too.

This imitative learning is a critical part of early development in toddlerhood but when this behaviour is a reaction rather than a learning mechanism, it is considered a copying behaviour (echophenomenon).

What causes echopraxia?

The causes of echopraxia aren’t clear, though it is a common symptom of Tourette syndrome.

Echopraxia on its own isn’t a medical condition. Rather, it is a symptom of a brain disorder or injury. It appears in people who have epilepsy, autoimmune conditions, autism, and major neurocognitive disorders (dementia).

It is also a common feature in culture-bound syndromes like latah, amurakh and imu. Culture-bound syndromes, also known as culture-specific syndromes, are a pattern of abnormal behaviour and mental illness that is unique to a specific cultural or ethnic population that can’t be classified as another standard psychiatric disorder.

Like echolalia, echopraxia is caused by brain dysfunction or brain disease and injury. It is known, for example, to occur when the brain’s frontal lobes have been damaged.

There is a theory that suggests the brain’s MNS (mirror neuron system) is to blame but, as yet, there has been no proven idea on how the activity of mirror neurons links with imitations.

It is only recently that researchers have identified mirror neurons. These unique cells fire up when a person performs an action but also when they observe the very same action being performed by another person.

One reason that it is so complex is that mirroring another person or mimicking their actions is a natural process of learning and human socialisation. When children learn about social reciprocity, they will imitate social gestures and repeat adults’ movements. The most obvious one is waving hello and goodbye. Babies actually begin copying actions and movements soon after their birth and this tends to disappear from the age of three.

Mirroring behaviours do still happen in adults too, though it’s not as common. If you see someone yawn, for example, you might feel the urge to yawn too. It’s only when these actions (not just yawning) become frequent that is it echopraxia.

What are the signs and symptoms of echopraxia?

As mentioned, mimicry is a natural behaviour in terms of social development. However, when people have echopraxia, they are unable to control these movements and do these mimicking actions involuntarily.

A person suffering from echopraxia might:

• Copy their teacher’s actions and body language – This could lead to school problems if it’s not recognised as echopraxia.
• Mimic movie characters’ actions or TV stars’ actions.
• Repeat harmful behaviours like punching or kicking.
• Mimic another person’s tics (if they see someone with Tourette syndrome either in person or online). There has been an increase in this since the Covid-19 pandemic and people spending more time on social media – So much so that the Tourettes Action Medical Director made a statement about it in January 2022.

Because these behaviours occur frequently, echopraxia can cause problems with relationships and social interactions. If people are unfamiliar with echopraxia then they might be offended by imitations and there could be misunderstandings.

Is echopraxia linked with other conditions?

As previously mentioned, echopraxia is not a condition in itself but a symptom of another condition or problem.

Echopraxia is seen in many conditions. These include:

• Schizophrenia.
• Tourette syndrome.
• Autism spectrum disorder.
• Aphasia (language deficits).
• Catatonia.
• Epilepsy.
• Dementia (major neurocognitive disorders).
• Some culture-bound syndromes.
• Autoimmune conditions.

Schizophrenia and echopraxia

According to a 2008 paper, it is estimated that up to 30% of schizophrenia patients have echopraxia. What’s more, in another small study, it was found that all patients were aware that they tended to imitate other people. In this study, echopraxia was determined to be more likely in patients that tried to communicate with others and was much more common when communicating became difficult.

Tourette syndrome and echopraxia

Echopraxia is one of the first indicators of Tourette syndrome. Tourette’s is a neurodevelopmental disorder that typically begins in adolescence or childhood that is characterised by both motor and vocal tics.

In Tourette’s, echopraxia is thought to be a variation of tics.

Unlike in schizophrenia, it is suggested that echopraxia in Tourette syndrome isn’t a result of a deficit in the MNS (mirror neuron system); rather it is a result of interference in the brain’s frontal lobe that regulates the control of imitation.

Autism spectrum disorder (ASD) and echopraxia

Though echopraxia does occur in autism spectrum disorder, it is much less common than it is in people who have other conditions like Tourette syndrome or schizophrenia.

Instead, it is much more common for autistics to have echolalia and copy language, accents and dialects.

There has been research to suggest that people with autism have reduced mirror neurons or mirror neurons that don’t function properly, which might explain communication differences in autistic people. However, there are many holes in this ‘broken mirror hypothesis’ research and more studies need to be carried out.

Aphasia and echopraxia

Echopraxia has also been seen in patients with aphasia. Aphasia describes a person who has problems with their speech or language. It is a common problem after a brain injury to the left side of the brain – after a stroke, head injury or brain tumour, for example.

Aphasia affects people in listening, speaking, reading, and writing or typing.

It is not understood why echopraxia co-occurs with aphasia but it is thought to be linked to trouble communicating.

Catatonia and echopraxia

Catatonia is a neuropsychiatric behavioural syndrome and it is complex. With catatonia, there are abnormal behaviours, abnormal movements, immobility and withdrawal. The syndrome has often been linked to schizophrenia but it is more common in mood disorders. Like echopraxia, catatonia isn’t a condition in itself but is a feature of some underlying problem.

The most frequently observed signs of catatonia are mutism, withdrawal, immobility, refusal to eat, rigidity, echolalia and echopraxia.

Epilepsy and echopraxia

Echopraxia has been reported as an ictal manifestation in people with left frontal lobe epilepsy. Ictal means that it happens when a seizure is occurring. Frontal lobe epilepsy is a common type of epilepsy that is characterised by frontal lobe seizures that typically last 30 seconds or less.

The brain’s frontal lobe is big and has many important functions. For this reason, seizures in the frontal lobe have unusual symptoms. These symptoms often seem like psychiatric problems or sleep disorders.

When people think of epilepsy, they usually think of the big, jerking seizures (tonic-clonic seizures). Frontal lobe epilepsy has a different presentation. You might see hand and eye movements to one side, unresponsiveness, a difficulty with speech, laughter, profanities and screams, strange body posturing, and repetitive movements.

It is this type of epilepsy where echopraxia can occur.

Dementia (major neurocognitive disorders) and echopraxia

Echopraxia can co-occur with dementia. There are many different symptoms of dementia and the most common issue is apraxia – when the body doesn’t respond to the brain’s messages like moving the fork to your mouth to eat.

When apraxia is apparent in a dementia patient, echopraxia might be seen too.

Culture-bound syndromes and echopraxia

Culture-bound syndromes were first defined in 1962. They’re also referred to as culture-specific disorders. As the name suggests, these disorders are patterns of behaviour that are locality-specific and can’t be linked to any other diagnostic category in the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders, fifth edition).

Examples of culture-bound syndromes that feature echopraxia include:

• Latah – A culture-bound syndrome in Malaysia and Indonesia that mainly affects middle-aged women. It is characterised by a startle response that’s exaggerated. Other symptoms besides echopraxia include echolalia, fearfulness, coprolalia (a compulsion to utter obscenities and profanities), disorganisation and command obedience.
• Amurakh – A culture-bound syndrome in Siberia that affects women. It is characterised by echolalia and echopraxia.
• Imu – A culture-bound syndrome similar to latah that affects Sakhalin and Ainu women in Japan. There is an extreme startle response, infantile reactions, and obedience to command too.

Autoimmune conditions and echopraxia

Some autoimmune conditions like autoimmune encephalitis have echopraxia as an associated symptom, though this isn’t always present.

How to manage echopraxia

Since echopraxia is a symptom rather than a disease or disorder itself, it is best managed by treating any underlying condition.

With echopraxia, there are often social challenges. One of the best ways of managing the condition is to inform people of its existence. Awareness by teachers and colleagues, for example, can help alleviate the stress and problems caused by involuntary mimicking.

If the echopraxia is caused by Tourette syndrome, people may learn to suppress it in social situations. However, suppressing tics often might lead to tic attacks later.

Another way to reduce and manage the symptom is by leading a healthy lifestyle. With adequate sleep, reduced stress and a healthy diet, tics and echopraxia can be reduced.

Above all, it’s important to remember that echopraxia is nothing to be ashamed of. Just like you wouldn’t be ashamed of having diabetes, epilepsy or asthma, people shouldn’t be ashamed of having echopraxia.

How is echopraxia diagnosed?

There is no definitive, formal test that diagnoses echopraxia. It becomes easier to diagnose from older childhood and can’t be diagnosed before the age of three. This is because young children naturally and frequently copy other people’s gestures and actions.

Imitation can be either imitative learning or automatic imitation. The former is when a person mimics an action consciously to learn it for themselves; for example, learning a golf swing. Imitative learning occurs from babyhood and is a way that young children learn. This behaviour should stop around age three, which is why echopraxia can’t be diagnosed before then. When imitative behaviour continues past infanthood, it could be echopraxia.

Older children, adolescents and adults report uncontrollable urges to imitate an action after they’ve observed it. This automatic behaviour is sometimes seen in healthy adults too – for example, in yawning, but this isn’t echopraxia.

Echopraxia is diagnosed by taking a medical history and by observation. A diagnosis will be based on whether the imitative behaviour seen and experienced is deliberate or involuntary. Intentional mimicry, for example, can be a person’s way of learning social norms and new skills.

How is echopraxia treated?

As previously mentioned, echopraxia will often involve treating an underlying condition, whether that’s schizophrenia, Tourette syndrome, or otherwise.

There is very limited research on how to treat echopraxia itself. However, many professionals say behavioural modification (like cognitive behavioural therapy), psychotherapy and medication (for people with a treatable condition) can help.

If a neurological disorder or brain injury is the cause then surgery to treat the problem might improve it.

If the echopraxia is mild and isn’t causing violence or self-harm, people often choose to manage it without specific treatment.

Final thoughts on echopraxia

Among the general population in the United Kingdom, not many will have heard of echopraxia, though they’re likely to be familiar with Tourette syndrome and even echolalia. Echopraxia isn’t a medical condition in itself but is a symptom of another underlying condition.

This symptom isn’t diagnosable under the age of three due to it overlapping with a natural way of learning in babyhood and infancy and there is no specific diagnostic test that will determine either way whether or not someone has echopraxia.

The main factor in the equation is whether the mimicking movements are involuntary or not. When someone copies another person’s behaviour in a repetitive and involuntary manner, it is likely to be echopraxia.

Managing the symptom and informing teachers and employers about the condition can help alleviate social issues and stigma. Treating underlying conditions where possible can also alleviate the symptoms.