What Is Agraphia?

Most people can transform their thoughts into written words with ease - from writing essays to shopping lists, humans are constantly writing down and spelling out the words in their heads. However, there is a disorder which can prevent this seemingly simple translation from thought to pen - this is known as agraphia.

Agraphia (or dysgraphia) is a neurological disorder which impacts a person’s ability to write or spell. The term encompasses a range of sub-disorders and can be caused in a variety of ways, from acquired brain injuries to Alzheimer’s disease. 

The following article will explain the disorder and its subtypes, as well as its causes and treatments. So, whether agraphia is a completely new concept to you, or you are looking for the answers to your questions, read on to find the scientific facts concerning this disorder.

Overview

Agraphia is a neurological condition that affects a person’s ability to write or spell. It often presents in conjunction with other neurological disorders such as aphasia (inability to understand and communicate using language) and acalculia (inability to perform mathematical or numeric tasks).¹ Most commonly, agraphia is associated with dementia and Alzheimer’s disease.²

Modern agraphia can take many forms; however, all revolve around an impairment in the ability to communicate through written language. ^1,3 In practice, this definition means that agraphia can describe a person who has a simple inability to spell, as well as a person who cannot write or draw at all. 

As a disorder, agraphia was first described medically in the 19^th century by the French physician Armand Trousseau in his book ‘Lectures on Clinical Medicine’, published in 1865.⁴ In his reports, Trousseau describes agraphia as a type of aphasia (an inability to communicate through speech or otherwise), stating that the disorder meant a person ‘could not put together loose letters of the alphabet’ following a traumatic brain event, despite previously being able to ‘write perfectly’.⁴

The disorder was more thoroughly studied in the 20^th and 21^st centuries, with neurologists such as Sigmund Freud and Carl Wernicke contributing to creating the modern definition of the term.⁵

Types of agraphia

There are two main types of agraphia: central agraphia (also known as linguistic or aphasic agraphia) and peripheral agraphia (also known as nonlinguistic or non-aphasic agraphia).³

Central agraphia

Central agraphia generally refers to a loss of language comprehension or communication through impairment of motor and visual abilities. Typically, this results from a brain injury or lesion. There are several subtypes of central agraphia:

Agraphia with Alexia

This is where both reading and writing ability are impaired and a person’s ability to comprehend language is affected. This does not necessarily have to include aphasia (impairment of the ability to speak).

Agraphia with fluent/non-fluent aphasia

These types all are in conjunction with aphasia. In agraphia with fluent aphasia, a person can produce written words; however, the content is nonsensical. In the non-fluent aphasia version, a person would produce words with letters missing and generally their quality of writing will be poor.³

Agraphia with conduction aphasia (phonological agraphia)

A person with this type of agraphia will be able to comprehend words; however, they have lost the ability to sound them out. This impairs the person’s ability to speak, and they will often repeat words many times with different pronunciations until the correct one is reached. A person with phonological agraphia will also have difficulty spelling and will have to individually memorise the spellings of words. This type of agraphia is slightly rarer than other forms.

Gerstmann syndrome agraphia

This is another rare form of agraphia in which a person will have difficulty discriminating between their own fingers, as well as the ability to tell left and right, causing an impairment in their ability to write. This is almost exclusively caused by lesions in the brain.⁷

Lexical agraphia

This is the opposite of phonological agraphia, in which a person can perfectly sound out words but cannot visualise the spelling.

Deep agraphia

This type of agraphia severely affects a person’s orthographic memory (the ability to remember how to visualise the spellings of words). A person with deep agraphia also mixes up closely related words when speaking or writing. For example, they may say ‘paper’ or ‘read’ when trying to say ‘book’.⁸

Peripheral agraphia

Peripheral agraphia often focuses solely on a loss of writing ability. Similar to central agraphia, there are several types of peripheral agraphia:

Apraxic agraphia (pure agraphia)

In apraxic agraphia, a person continues to have a knowledge of language and words, as well as the ability to spell them. However, they are not able to use their hands to write these words down. This is commonly caused by damage to the parietal, frontal or temporal lobe.⁵

Ideational agraphia

In a way, this is the opposite of apraxic agraphia. A person may have some motor control over their hands in order to write, however, they no longer possess the knowledge of the concept of writing itself. The person will often retain the knowledge of spoken language. This is a particularly rare form of agraphia.

Visuospatial agraphia

A person with visuospatial agraphia will have knowledge of writing and be able to write letters, but they will have some issues correctly orienting writing utensils. They will often only be able to see half the page at a time, words may seem jumbled, and their handwriting will slope upwards or downwards. They will occasionally superimpose their writing and find difficulty spacing words apart. This is often due to optic ataxia (difficulty perceiving depth).³

Reiterative agraphia

This type of agraphia will cause a person to repeat words, phrases or letters as they write.³

‘Writer’s Cramp’

This occurs when people who handwrite using pens experience pain or spasms in the hand whilst writing. It is classed as a type of localised, apraxic motor agraphia. The cure is often an injection of botulinum toxin (botox) into the hand.⁹

Causes of agraphia

Agraphia is almost always acquired during life through brain injury. All forms of agraphia are often caused by lesions to the cortical language centres of the brain or any of their subcortical sections. One of the leading causes of this damage is stroke, which is also the most widely studied cause. Nonetheless, brain damage leading to agraphia can also be caused by head trauma, tumours, infection, transient headaches, Alzheimer’s disease, dementia and Parkinson’s disease.⁵ 

Signs and symptoms of agraphia

The specific symptoms for each type of agraphia are outlined in the different types above. These symptoms can all be summarised by difficulties in comprehending, writing or communicating using words. 

The signs of agraphia will be clear to many observers. A person with mild agraphia will have an overall lower quality of writing, ‘messy’ handwriting and poor spelling. A person with one of the more severe forms of agraphia will be unable to comprehend words or write at all.

Management and treatment for agraphia

The disorder can often be treated by addressing the root cause of the issue. For example, if a person has developed agraphia from a traumatic brain injury, the therapy and treatment for this event will most likely lead to improvement in the disorder.

Most sufferers of agraphia will benefit from speech and language therapy (SLT). This treatment is often used for people who have experienced a stroke and will help to ‘re-learn’ language once again.³

In general, the best treatment for agraphia is the identification of the cause of the disorder and treating it. In this sense, agraphia can be described as more of a symptom than a disease in itself.

Diagnosis of agraphia

People who have experienced or are at risk of brain injuries, such as stroke or Alzheimer’s, are often tested for agraphia during their recovery. They will be asked open-ended questions such as ‘What did you do today?’ or ‘Tell me a fact about yourself’, then asked to write their answer. They will then be assessed on their writing speed, legibility, spelling and spatial awareness of the page.^3,10 There are no quantitative tests for agraphia. 

FAQs

Can agraphia be prevented?

No - agraphia is often acquired after a brain injury and therefore cannot be prevented directly.

How common is agraphia?

Agraphia has a high incidence in stroke victims and is common in conjunction with other neurological disorders such as aphasia and acalculia. It is rare for agraphia to present in otherwise healthy people.

What can I expect if I have agraphia?

Majority of people with agraphia can expect to live a full, healthy life in spite of the disorder. Many patients find ways of overcoming their communication issues with the help of modern technology and SLT therapy.

When should I see a doctor?

If you suspect you may be experiencing symptoms of a brain injury, such as agraphia, see a doctor as soon as possible. 

Summary

Overall, agraphia is a neurological disorder which affects a person's ability to communicate using words through writing or speaking. It can take a wide variety of forms and is currently not well understood. Treating this cause of the disease is often the best treatment for agraphia. Outside of this, speech and language therapy (SLT) is a more targeted approach.