Overview

Abilities like speaking, reading and writing are commonly acquired and developed throughout life, depending on culture and personal needs. Brain damage to regions that specialise in communication can affect just one or a combination of these skills. Alexia, aphasia, and agraphia are all specific names that refer to the type of ability affected.¹

graphia is described as the loss or impairment of a previous ability to write. It has a few causes, such as strokes, tumours, infections or physical trauma. It may be related to language deficits or manifest itself from different triggers, such as motor disability. Once the brain lesion is confirmed, assessing the patient's literacy and writing skills is part of the diagnosis.²

Individuals who are manifesting signs of agraphia present impairments related to their brain’s communication processes. Phonological awareness, word recognition, comprehension, spelling, sentence composition and handwriting are all skills that depend on each other and share tools developed by the body to properly function. Those can all be compromised in the face of agraphia and its consequences in daily life.¹

Types of agraphia

The rare occurrence of pure agraphia is described as a patient’s struggle with writing while verbal language and reading skills are intact. However, agraphia is usually associated with other communication impairments. It can be divided into two large categories: central (related to language skills) and peripheral (not related to language skills).³

“Language performance requires support from central cognitive/linguistic abilities as well as the more peripheral sensorimotor skills to plan and implement spoken and written communication.”⁵

Central agraphia

Central agraphia is a type of agraphia that mainly affects linguistic mechanisms. It can manifest in different and specific ways. Patients may struggle with language structure when writing; use fewer words and letters than needed, causing misspellings and lack of connection between ideas; no spelling issues, but confusing phrase building with nonsense content; repeatedly misusing words that are written similarly to the one intended. 

Agraphia may manifest as isolated and not involve any other communication resistance, but it is mostly associated with aphasia (comprehension debilitation) or alexia (reading debilitation).¹

Peripheral agraphia

Peripheral agraphia is a type of agraphia not dependent on linguistic mechanisms. The inability to write can arise from issues in motor functions, this is called apraxic agraphia. When the sense of space related to the act of writing gets affected, the appropriate term is visuospatial agraphia. The person can be unaware of the whole extension of a page, group words or put too much space within a sentence or a text. Functional (or psychogenic) agraphia is complex to frame as it manifests as a symptom of an unspecified neurological disorder.¹

Causes and risk factors

• Neurological conditions: stroke, traumatic brain injury, dementia, brain tumours
• Developmental factors: learning disabilities, genetic factors
• Environmental factors: lack of exposure to written language, and educational opportunities

Symptoms and diagnosis of agraphia

Common symptoms 

• Difficulty with spelling 
• Illegible handwriting 
• Omissions, additions, or substitutions of letters 
• Difficulty with sentence structure 

Diagnostic tools and procedures 

Diagnosing agraphia requires a complete neurologic examination. Specialised health professionals perform cognitive and language analysis. It is based on assembling information on the patient's reading, comprehension, fluency and other communication skills. Writing samples are also required. Clinically, as a confirmation, image exams can show evidence of brain injury to corroborate the case.⁴

Impact on writing and reading skills

Phonological awareness

The ability to write consists of a combination of different cognitive capabilities, spoken language being one of them. The patient's performance in phonological tasks can reflect their agraphia and related impairments status. Defining, recognising, and producing the sound of words, letters, numbers and other symbols falls into the category of phonological skills, which depend on tools to associate spoken language with writing. Phonological functions are the bridge between written language and its associated sounds when spoken.

Being able to cross this bridge depends on tools developed in childhood. People who live with agraphia can manifest difficulties crossing this bridge. While crossing, it seems normal, even though they don’t come to the other side, but for someone looking from the outside, the bridge is not functioning properly. Building awareness around the patient’s defective phonological tools, by itself, is part of the treatment to overcome it.⁵

Decoding and word recognition

Identifying letters, symbols and numbers can be challenging for someone presenting difficulties in writing and reading. The obstacle might refer to any graphic element or a few in isolation. A study by Delazer⁶ describes a patient who properly decodes and writes the number 0, but can not do the same with the letter O. The subject of the study presented a type of agraphia that did not affect their perception of Arabic numerals, only the Roman alphabet. The different elements require different routes for the brain to process them.⁶

Likewise, individuals may not be able to recognize written words but can easily identify them when spelt out loud. They can work to recover the ability to recognize and name individual letters. Because of that, they can develop a reading process that happens letter by letter, compromising reading fluency. Pauses and hesitation when reading can also be affected by a lack of efficiency in access to memory to connect the meaning of words to their written form.⁷

Comprehension difficulties

It is common for individuals with agraphia and related impairments to suffer with comprehension in general. The ability to understand written content is compromised, regardless of whether reading is done silently or out loud. It can happen for words, numbers and musical notes.⁵ Even when recognizing the correspondent sound in spoken language, the meaning might not be connected and comprehension of speech is defective.⁶

Spelling and sentence composition

Confusing sentence building and difficulty in written expression are common with agraphia. Individuals might write skipping letters, misspell words with others that sound similar, use spaces out of place and struggle to connect ideas because of that. It affects both the sentence structure and meaning, making it hard for the individual to express what they want to.^1,9

Handwriting

Handwriting can be compromised with individuals with agraphia. They may require a long time to write, have a slow reaction to start writing, ineligibility, lack of consistency, presenting significant variations in handwriting appearance. It usually presents in forms of agraphia that manifest because of motor impairments.¹⁰

Strategies for treatment

Defining the type of agraphia is essential for the treatment, as a variety of brain damage can cause the disorder. A patient with writing impairment due to a tumour may need a completely different strategy for treatment than a patient with writing impairment due to Parkinson’s Disease. Individuals suffering from either central or peripheral agraphia usually are prescribed speech, language and occupational therapy.

Many cases require a multiple approach, combining therapy, medication and even surgery. Despite that, cases of peripheral agraphia may present more peculiar approaches, visuospatial type can require special lenses, while motor type may benefit from botulinum toxin injection, for example. It all comes down to the origin of the disorder, if it is a growing issue and how it affects the patient.¹

Summary

Agraphia comes from a branch of impairments that affect previously established skills. It manifests after a brain injury affects specific regions responsible for mechanisms connected to the ability to write. These brain injuries can happen after physical trauma, tumours, strokes or infections, for example.

Agraphia can present on its own but is often combined with other impairments related to speaking, reading and comprehension. It affects the ability of many patients to communicate properly, compromising the linguistic tools developed since childhood and throughout life. Spelling, handwriting, speech comprehension, building sentences with cohesive ideas, linking words to their meaning, recognizing letters and numbers; cognitive processes involved in writing can affect endless skills that are essential in daily life and, usually performed automatically.

Agraphia establishes a significant obstacle in the patient's routine making it hard to work, socialise, enjoy leisure activities, and take care of themselves. It results in a decreased quality of life and, in many cases, the need for constant assistance. A variety of treatment approaches are possible depending on the origin of the patient's agraphia, but they often rely on speech and language therapy to relearn communication skills.