Agraphia: Everything on This Writing Disorder

 

Writer’s block comes with this job. There’s always a moment or two (or three) when I feel my brain can’t seem to put down in words what I want so earnestly to express to my readers. Perhaps that’s why this topic feels so dear to me. My heart goes out to those with this advanced problem. We will look into this disorder called agraphia and to understand how writing can be impaired. The power to communicate through the written word is extremely valuable, and so we will discuss how clinicians try to give patients back their power to communicate.

agraphia
Agraphia affects the ability to communicate through written language.

What is Agraphia?

Agraphia (dysgraphia in most of Europe) causes a loss of written language. When parts of the brain are damaged, we risk losing the complex mechanisms that allow us to put our thoughts into written communication. The way agraphia manifests depend on the way the brain is damaged. With agraphia, the dysfunction goes far beyond a little writer’s block. It is an impairment in writing abilities due to brain damage. There are different deficits that can show up with writing. Those with apraxic agraphia have difficulty writing despite retaining spelling and verbal skills. Writing, reading, and speaking are all related to the human language ability so you might come across this term  in relation to other terminology of language, including:

  • Aphasia, an acquired disorder of language
  • Agnosia, an inability to interpret sensory information
  • Apraxia, an inability to perform motor movements
  • Alexia: an acquired disorder of writing

Evidence suggests that aphasia, alexia, and agraphia are related to the same neural network, so it is not surprising that patients may have a combination of these deficits. The specific sites for reading and writing have been harder to pinpoint, but studying patients with agraphia gives us clues.

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1553 is the earliest documentation of a case of agraphia: Thomas Wilson identified a patient who had writing impairments while still retaining the ability to produce speech. This would classify today as acquired. A true investigation into language disorders didn’t start until the 1800s when the relationship between the brain and language was a point of the study. They key scientists in this time were Paul Broca, Carl Wernicke, and William Ogle. Broca was the one to discover that the left frontal lobe was responsible for speech production, while Wernicke was the one to identify that the left temporal lobe was responsible for speech comprehension (see Broca’s aphasia and Wernicke’s aphasia).

Agraphia
Agraphia and reading impairment are often connected. 

Types of Agraphia

Central Agraphia

Central agraphia is a type of disturbance which involves dysfunction in both languages (aphasia) and the motor skills for writing. With central agraphia, there is a struggle with selecting the correct words or spelling and understanding the meaning of words on paper. This is tied to what is considered the “central language” process of the brain. There are several sub-types within this category:

  • Deep agraphia: due to brain lesions, the patient cannot remember how to spell words or recognize them. Often, they will rely on memory of sounding the word. out, but this will lead to errors such as “Kum” for come or “Kome” for comb.
  • Aphasic agraphia: written and spoken language is impaired.
  • Alexia with agraphia: Patients cannot produce  or comprehend written language.
  • Agraphia of Gertsmann’s syndrome: writing impairment in conjunction with math impairment (acalculia) left-right confusion, and finger agnosia.

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Peripheral Agraphia

Peripheral agraphia is impairment in the motor and visual functions involved in writing. The disruption is in the peripheral language skills involves selecting the proper string of letters and the motor function to write it down. Examples include:

  • Apraxic agraphia: also known as pure motor agraphia. The specific function for using the hands to write out words is disrupted, while the verbal functions are intact. As a result, patients can spell correctly if asked to spell out loud, but letters cannot be formed on paper or are extremely ineligible.
  • Reiterative agraphia: when writing, letters, words, or sentences get uncontrollably repeated. This can manifest as over repeating phrases said out loud by the affect person, or over repeating phrases said by a clinician to the patient.
  • Visuospatial agraphia: The visual-motor coordination of writing is disrupted. In such cases lines in letters are abnormally long, or there is extra long spacing in between letters or words.

Agraphia
Some people with agraphia struggle to write legibly.

Neurological Causes of Agraphia

Agraphia is considered an acquired impairment. It is acquired when there is damage or lesions to parts of the brain that control the writing or language process. Very roughly speaking, the brain is divided into the cerebellum (motor movement) and 4 lobes of function: frontal (reasoning and higher-level thinking), occipital (vision), parietal (processing body senses), and temporal (memory and language).

Neurologists recognize that damage to specific areas of the frontal lobe, parietal lobe, temporal lobe, and cerebellum are what impact writing.  Makes sense, as we need our language, reasoning, memory, and motor skills to write. Stroke, traumatic brain injury, and dementia are types of brain damage that can cause agraphia. Here are some documented examples:

Stroke: One study documented a 67 year-old Japanese man who developed pure agraphia, which meant he had impairment in writing Japanese characters without any other cognitive or language deficits. The deficit was attributed to hemorrhage in his left superior parietal lobe.

Traumatic brain injury: A 31-year-old college educated male suffered a moderate head injury during a traffic accident. A written sample he provided showed several errors in spelling and preservation (repeating words). This was indicative of a rare form of agraphia known as frontal lobe agraphia.

Dementia: A 61-year-old male developed cognitive impairment, which progressed to severe dementia after two years. During the two years, his sentence writing worsened, with letters and word spacing become more disjointed. Neuroimaging studies showed his dementia to be attributed to deterioration in the frontal-temporal area.

Treatment for Agraphia

With agraphia, the brain damage cannot be repaired. Therefore, clinicians focus on rehabilitating patients to regain their writing abilities.

Relearning How to Write

Doing this requires patients to go back to the basic of language. As children, we learn the shapes of letters and how those letters are associated with sounds and from there we can combine letters into a body of words that build into sentences and concepts. There is a direct link between the written production of language (orthography) and spoken production (phonology) and in between, the knowledge of meaning behind words (semantics). How writing is relearned depends on whether the type of agraphia is related to problems in phonology, orthography, or semantics.

Agraphia
Treatment for agraphia involves relearning basic units of words.

For lexical agraphia, the problem is orthography: the patient loses memory of spelling or how to visualize spelling of the word. To solve this, some clinicians will use copy and recall treatment (CART) that trains patients to copy target words that have been written out for them. For example, if I am treating a patient named Sarah, I will write out “Sarah” for her on paper and have her copy down “Sarah” over and over. I will then cover up what has been written and have Sarah try to recall what we wrote down and write it again.

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For phonological agraphia, the problem is not with spelling, but sounding words out. The key will be to have patients better understand which sounds corresponding to written letters. Clinicians will give “key words” which the patient knows and can consistently spell right. For example, “apple” for the letter a; if the patient at least knows that apple starts with an “a”, the word can be used as a bridging point to help the patient retrieve the letter “a”. This type of treatment can be compromised when letters can have multiple sounds (“c” as in nice or “c” as in “cake”) but is helpful in building correct spelling knowledge.

More global agraphia means that writing impairment is co-morbid with aphasia or alexia. Because of these general language problems, clinicians will focus on improving written language as an alternative for patients to communicate. One treatment is to have patients unscrambled letters into meaningful words (anagrams) and copy those words over and over. This trial and error method helps patients to practice correct spelling.

Agraphia
Anagrams can help treat some types of agraphia.

For peripheral agraphia, the issue has more to do with the motor movements required for writing. Treatment will be based on letter selection and retaining the hand coordination to write legibly. For example, patients will be given cards with the printed alphabet, so they have a model to re-create the letter shapes. Patients with intact verbal communication can also verbalize the letters to help them select the correct ones to write down.

Does agraphia affect typing?

One thing to note is that in the growing age of technology, some might ask: who actually writes anything on paper? Indeed, with so much of our written communication being performed on a keyboard of some sort, it is worth considering how typing might be a great substitute for people with writing deficits. The good news is research shows that individuals with apraxic agraphia might be able to compensate for motor impairment by typing rather than handwriting. This may become a welcome rehabilitation tool for many who struggle to even hold a pencil.

People who have suffered strokes, dementia, or traumatic brain injury should make sure resources are in place to diagnose language impairment. Neuropsychological assessments are used as tools to identify reading impairment. One of them includes the John Hopkins University Dysgraphia Battery, which uses sub-tests to assess writing ability. Single-word reading can be assessed with the Arizona Battery for Reading and Spelling. Knowing about reading problems at the early stage is key for rehabilitation.

References
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Bennett, C. N., Rajeswaran, J., Sampath, S., & Christopher, R. (2013). The Right to Write: EEG Neurofeedback Training in Frontal Lobe Agraphia-A Case Report. Journal of Neurotherapy, 17(3), 162–165. https://doi.org/10.1080/10874208.2013.813174
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Nana is a new collaborator for CogniFit. When not writing he works as a University research specialist, focusing on clinical assessment of brain injury. He received his BA from Dartmouth College and recently completed his Master of Public Health degree at the University of Ghana. His MPH dissertation was on cognitive impairment in Africans living with HIV. His interests are in neuropsychology, abnormal psychology, and cognitive disorders. Feel free to provide feedback on the articles he shares.