This episode is a quick take in a new intermittent series I am calling “In a Word,” and in this series I hope to dig down into some neuropsychiatric terms that we use every day, but maybe don’t really understand very well. The first word I am taking on is PERSEVERATION. The reason I chose PERSEVERATION is because I see it written in psych notes by med studs and residents frequently, but for you Princess Bride fans out there, “You keep using this word. I don’t not think it means what you think it means.”
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Welcome to PsyDactic - Residency Edition. I am Dr. O, currently a second year Psychiatry Resident. This episode is a quick take in a new intermittent series I am calling “In a Word,” and in this series I hope to dig down into some neuropsychiatric terms that we use every day, but maybe don’t really understand very well. You can find my references at the end of the show transcript at psydactic.buzzsprout.com.
The first word I am taking on is PERSEVERATION. Autocorrect and predictive text algorithms are likely to correct this word to preservation but it means something very different. The reason I chose PERSEVERATION is because I see it written in psych notes by med studs and residents frequently, but for you Princess Bride fans out there, “You keep using this word. I don’t not think it means what you think it means.”
Most often, I have written or seen it written in the Mental Status exam under the thought content or the thought process section, which is reasonable. However, I find it most often used as a synonym for rumination or brooding, when a patient continues to return to a subject of thought like how he is going to win back his ex-wife or what she did wrong in the meeting to make everyone hate her. I also found a 2021 paper in the Journal of Behavioral Medicine titled, “Worry and rumination in breast cancer patients: perseveration worsens self-rated health.” This paper explicitly uses perseveration as a synonym for worry and rumination.
I am going to propose that as psychiatrists, we should not use perseveration as a synonym of brooding or worry or rumination. We already have words for that and since we are boarded by the same entity that boards neurologists, we should have a very precise and shared language. Perseveration is a neuropsychological phenomenon with proposed mechanisms, and for clear and effective communication and diagnosis, I think it deserves to be treated that way.
But before I get there, I want to mention a couple other things that a perseveration is NOT. It is also not an obsession nor a compulsion. Obsessions are repeated thoughts and compulsions are repeated actions, but as a psychiatrist, it would be as wrong to call a rumination, “an obsession,” as it is to call a compulsion, “a perseveration.”
If you are thinking Dr. O, you keep telling me what perseveration is not, but you still haven’t told me what it is, then you are right.
Let me share a few published definitions of perseveration I have come across without having to pay $30.00 to the knowledge keepers. The first is from a paper “Perseveration in Alzheimer’s Disease” by Pekkala et al from 2008 in the journal Dementia and Geriatric Cognitive Disorders. Perseveration is [quote] “any continuation or recurrence of an earlier verbal or nonverbal response without an appropriate intervening stimulus.” [unquote]
This is admittedly very vague so let me give you an example from another paper from Possin et al in the Journal of Clinical and Experimental Neuropsychology rom 2005: [quote] “In general, a perseveration is the inappropriate and unintentional persistence of a behavior.” Wow, not much less vague.
Knowing that perseveration is not rumination and it is not an obsession or a compulsion, we can understand it as the name we give to some action or vocal expression which at some point seemed to serve a purpose but is repeated in a way that has become purposeless. This distinguishes it from other purposely repeated actions like tics or chorea, which were always purposeless or their purpose is only to relieve an urge and not to accomplish a task.
Papers dealing specifically with perseveration often point out that there are two competing ways of understanding it. There is the Sandson and Albert model and the Goldberg model. Per the Goldberg model, all perseveration is explained by the inability of the brain to switch from one task to another, and is a failure of the executive system primarily controlled by the frontal lobes. Per the Sandson and Albert model, perseveration can be the result of three different failures in the brain. They describe these failures as “stuck-in-set,” “recurrent,” or “continuous.”
Someone with stuck-in-set perseveration is unable to effectively change the framework in which their brain is operating. This might be apparent if you ask someone to name vegetables and then ask them to name animals, but they continue to name vegetables. Set switching is thought to be an executive function of frontal regions and their connections with the subcortical and mesolimbic system. Somehow, there is impairment of the ability to change a response, such as a word to fit a new category. Also, imagine someone is given a hammer and nails, then presented with a driver and a screw, but instead of twisting in the screw, they use the screwdriver like a hammer.
The next type of perseveration is recurrent perseveration and is thought to be a dysfunction of temporo-parietal regions and memory function. It is called recurrent because it isn’t a continuous or stuck-in-set action, but an action that occurs after some intervening despite having already occurred and fulfilled some purpose. I am reminded of what frequently happens when I ask my patients to name all the words they can that begin with the letter F which might look something like this: fire, fork, freeze, fire, fun, freight, fire. In this example, the word fire is not repeated continuously, but recurs despite already having been stated. Someone might perseverate on their door being locked without it mounting to an obsession if they, for example, lock the door upon entering, check the lock again after putting up their key, and then check the lock again after hanging their jacket. If the action is automatic instead of driven by a compulsion, then it is recurrent perseveration. It is driven by the brain not having fully registered completion of the action and not on a feeling that it needs to be done again.
The last type of perseveration in the Sandson and Albert model is the continuous type, where an action or word is repeated without interruption, despite having fulfilled its original intent. These perseverations are thought to be related to dysfunction in the motor cortex, the basal ganglia, or communication between both of these entities. It is like a loop that can’t be turned off. As it loops it might also degenerate into an action or word that is somewhat similar to the first but fragmented or partial. Some suggest that similar mechanisms are involved in phenomena like echolalia and echopraxia, where patients automatically repeat back or mimic what the provider has said or done. Also related may be logoclonia, where patients repeat back often the last syllable of a word, similar to the goose in Charlotte's Web. “I’m no fliberdy, inberdy, jibit.”
I hope that this discussion of PERSEVERATION has left you with more than just, “That Dr. O’Leary guy is kind-of an a-hole.” I do think that it is important that our words have precise meanings when possible. I think it helps us to organize our thinking, and also to communicate more efficiently. Next time you talk to your neurology colleagues and say something like, “She is perseverating on her losses,” you won’t have to explain to them that she is not continuous looking in her purse for her cell phone despite having already done that 5 times in a row, but instead she is ruminating on how empty and alone she feels right now.
I am Dr. O, and this has been an episode of PsyDactic - Residency. 1–5
1. Renna ME, Rosie Shrout M, Madison AA, et al. Worry and rumination in breast cancer patients: perseveration worsens self-rated health. J Behav Med. 2021;44(2):253-259. doi:10.1007/s10865-020-00192-9
2. Possin KL, Filoteo JV, Roesch SC, Zizak V, Rilling LM, Davis JD. Is a perseveration a perseveration? An evaluation of cognitive error types in patients with subcortical pathology. J Clin Exp Neuropsychol. 2005;27(8):953-966. doi:10.1080/13803390490919092
3. Giele CL, van den Hout MA, Engelhard IM, Dek ECP, Hoogers EEP, de Wit K. Ironic effects of compulsive perseveration. Memory. 2013;21(4):417-422. doi:10.1080/09658211.2012.727006
4. Kaufmann C, Agalawatta N, Malhi GS. Catatonia: Stereotypies, mannerisms and perseverations. Aust N Z J Psychiatry. 2018;52(4):391-393. doi:10.1177/0004867418765669
5. Pekkala S, Albert ML, Spiro A, Erkinjuntti T. Perseveration in Alzheimer’s disease. Dement Geriatr Cogn Disord. 2008;25(2):109-114. doi:10.1159/000112476