Overview

Agraphia is an umbrella term that describes when a patient loses the ability to write. This is due to a variety of reasons, and it is usually associated with brain injury. Handwriting becomes like second nature once you master the skill. However, it is a very complex task that requires at least 12 different regions of the brain and involves integrating motor skills, language, attention, and coordination.¹ Agraphia can fit into two categories: central and peripheral. The central and peripheral categories also have subtypes of agraphia. Therefore, it is important to know about the different subtypes and categories of agraphia, as knowing which agraphia a patient has specifically can help in treatment.

Central agraphia

The brain is made up of several key regions that are all mainly responsible for a main task. However, there is communication between these brain regions, and they all coordinate to achieve skills, for example, handwriting. Central agraphia means that one of these regions associated with the skill of handwriting is damaged or changed. It usually means that patients present with spelling or spontaneous communication issues and other language disorders.² However, there are subtypes of central agraphia depending on the damaged brain region.

Receptive aphasia

It is a type of aphasia in which there is a problem understanding written and spoken language. The letters are recognisable, but they are unable to write anything meaningful. The cause of this type of aphasia is damage to the area of the brain known as Wernicke's area, which is responsible for selecting the appropriate words depending on the situation.³

Expressive aphasia

In expressive aphasia, Broca's area of the brain, which is in the front of the brain, is damaged. The patients have difficulty speaking suddenly and usually have grammar issues. There is also a loss of linking words, for example, "or," "but," and "and." There may be long pauses between words. Patients can write short sentences, but it takes a lot of energy for them to write.⁴  

Alexia

Alexia can occur with and without agraphia. Patients with alexia have problems with understanding reading. When it is in conjunction with agraphia, they are also unable to write.⁵

Deep agraphia

Patients with deep agraphia have issues with spelling words and are not able to sound out words; there are also issues with uncommon words and abstract concepts; this means that these patients usually have issues with reading and speaking as well.⁶

Developmental gerstmann syndrome

There is a high overlap between developmental Gerstmann's syndrome and dyslexia; however, it is important to know the differences as it can help aid in the treatment. A study has found that children with handwriting issues have a higher risk of becoming anxious at school and getting more tired of schoolwork. Developmental Gerstmann's syndrome is associated with motor, sensory or reflex responses. Dyslexia can be passed down through families, and patients usually have issues with reading and writing and also have poor text scanning skills, but also no problems performing daily tasks, whilst patients with developmental Gerstmann syndrome typically have issues with eye-hand coordination, it is not passed down through families, and have constructional apraxia which means that they are unable to copy or draw an image. There are, of course, different degrees of this syndrome; out of 10 children, three children could not copy letters of the alphabet, but seven kids were able to reach some writing milestones but had severe spelling mistakes or substantial errors. The kids also have temper tantrums associated with having to perform writing tasks.⁷

Lexical and structural  

Patients have damage to their orthographic memory, which means that the patients are unable to visualise the spelling of the word; they can sound the words, but they may have issues with spelling words that are pronounced the same but have different meanings such as “night” and “knight”.⁸

Phonological

Patients with phonological Agraphia cannot spell pronounceable non-words and have a retained ability to spell irregular words that are dissociated from pronunciation.²

Pure agraphia

Patients with pure Agraphia have an isolated incidence of the Agraphia and no other language impairment.²

Peripheral agraphia

Peripheral Agraphia describes the type of Agraphia in which it is not the brain areas that are associated with language that are damaged, but the areas of the brain that are involved in motor output are damaged.⁹

Reiterative

The patients have issues with the motor execution of writing. This is caused by damage to the motor system and can manifest as the patient is unable to rewrite a phrase that they were previously able to write before the damage.¹⁰

Visuospatial

Patients with visuospatial Agraphia have issues with how to organise their writing. This often results in slanted writing and/or writing that focuses on only one area of a page. It is associated with damage to the right hemisphere, which is an area of the brain.¹¹

Diagnosis

Agraphia is a rare disorder and therefore to rule out that it could potentially be another disorder a full neurological workup is required. This involves testing the patient’s language skills including reading, fluency and written language. An example is the patient being asked to write a sentence to a list of questions such as “What did you do today?”, “tell me something about yourself”. If it is suspected after the neurological workup that agraphia is the cause of the problems with written language then the patient will be referred to receive a CT or MRI, to determine which area of the brain is potentially damaged. CT and MRI scans are useful methods to visualise the brain, a CT scan involves the patient lying on a bed whilst in a tube-like structure that has an X-ray scanner to be able to see the brain, MRI is a similar method except it uses magnets and radio waves instead of x-ray scanning.¹⁰

Treatment and management⁸

Because Agraphia central and peripheral are not usually present in isolation, there is not a single treatment for this condition; most of the time, there is a recommendation for speech and language therapy, also abbreviated to SLT. The types of treatment that can be expected will be highly based on the individual and which Agraphia they are diagnosed with. This is because there are differences in the way the writing is affected in each individual, even if they are diagnosed with the same type of Agraphia.

Copy and recall treatment⁸

Copy and recall treatment, also known as CART, is helpful for patients with central Agraphia, such as phonological and lexical Agraphia. It involves a patient being given a small set of target words that are then repeatedly practised. This can be during sessions or given as homework. The important part of this treatment is repetition before the next set of target words is chosen, as it helps to reinforce the words in the patient's brain before beginning to learn a new set of words.

Problem-solving approaches⁸

This approach is most useful for lexical Agraphia as it allows the patient to connect the lexical and phonological connection that has been damaged because the patients usually have a preserved skill of sounding out the words, so the patients are taught to self-correct the errors that they make when they spell a word and are encouraged to attempt different possibilities of the spelling. This technique is aided with electronic spell checking which then provides a list of options for what the patient was trying to spell and then must choose the correct spelling of the word. This technique also involves homework in which the patient is asked to write paragraphs about things that interest them and then are asked to identify any spelling mistakes and rewrite them without the spelling mistakes. This approach allows the patient to identify mistakes themselves and allows the connection between the phonological and lexical areas to be re-established.

Anagram and copy treatment⁸

This method is mainly used with phonological Agraphia, where the patients are presented with an anagram and asked to rearrange it and then copy the target word. This method helps strengthen the orthographic memory and is less taxing on the patient than writing from scratch. The mental representation of the written word using this method becomes better. This method is similar to the CART method. However, this one also allows meaning to be attributed to the word.

Peripheral agraphia⁸

Because peripheral Agraphia is usually associated with motor problems, there is an emphasis on typing, as it requires different motor skills than handwriting. There is also training that teaches patients how to use self-dictation to spell if typing is not possible.

Overall

Overall, if you suspect that you may have central or peripheral Agraphia, then it is best to record your symptoms and go to a specialist. There is some overlap between Agraphia and disorders such as dyslexia; however, there are distinct differences that are important to note. Having the correct diagnosis can help improve the symptoms that are being experienced.

Summary

Agraphia is the loss of the ability to write, often due to brain injury, and involves various brain regions. It is categorized into central and peripheral agraphia. Central agraphia results from damage to brain areas related to language and writing, with subtypes such as receptive aphasia, expressive aphasia, alexia, and deep agraphia. Peripheral agraphia, on the other hand, involves motor output problems and includes subtypes like reiterative and visuospatial agraphia. Diagnosis requires a full neurological evaluation, including CT or MRI scans, to pinpoint brain damage. Treatment typically involves speech and language therapy (SLT), with approaches like Copy and Recall Treatment (CART) and problem-solving strategies tailored to specific agraphia types. For motor-related peripheral agraphia, typing and self-dictation may be emphasized. Early diagnosis and appropriate treatment can improve writing difficulties and quality of life for affected children.