Agraphia: When Writing Isn’t as Easy as ABC
Imagine deciding to jot down a list of items you need from the grocery store and finding that you have no idea what letters spell the word bread.
Or penning a heartfelt letter and discovering that the words you have written make no sense to anyone else. Imagine forgetting what sound the letter “z” makes.
This phenomenon is what’s known as agraphia, or the loss of the ability to communicate in writing, stemming from damage to the brain.
What is agraphia?
To write, you have to be able to execute and integrate many separate skills.
Your brain must be able to process language. In other words, you must be able to convert your thoughts into words.
You must be able to:
- choose the right letters to spell out those words
- plan how to draw the graphic symbols we call letters
- physically copy them with your hand
While copying the letters, you have to be able to see what you’re writing now and plan what you’ll write next.
Agraphia occurs when any area of your brain involved in the writing process is damaged or injured.
Because both spoken and written language are produced by intricately connected neural networks in the brain, people who have agraphia usually also have other language impairments.
People with agraphia often also have difficulty reading or speaking correctly.
Agraphia vs. Alexia vs. Aphasia
Agraphia is the loss of the ability to write. Aphasia usually refers to the loss of the ability to speak. Alexia, on the other hand, is the loss of the ability to recognize words you once could read. For that reason, alexia is sometimes called “word blindness.”
All three of these disorders are caused by damage to language processing centers in the brain.
What are the types of agraphia?
What agraphia looks like varies according to which area of the brain has been damaged.
Agraphia can be broken into two broad categories:
It can be further subdivided according to which part of the writing process has been impaired.
Central agraphia refers to a loss of writing that stems from dysfunction in the language, visual, or motor centers of the brain.
Depending on where the injury is, people with central agraphia may not be able to write understandable words. Their writing might have frequent spelling errors, or the syntax may be problematic.
Specific forms of central agraphia include:
An injury to the left parietal lobe of the brain sometimes damages the ability to remember how to spell words. This skill is known as orthographic memory.
With deep agraphia, a person not only struggles to remember a word’s spelling, but they might also have a hard time remembering how to “sound out” the word.
This skill is known as phonological ability. Deep agraphia is also characterized by semantic errors — confusing words whose meanings are related — for example, writing sailor instead of sea.
Alexia with agraphia
This disorder causes people to lose the ability to read as well as write. They may be able to sound out a word, but they can no longer access the part of their orthographic memory where the word’s individual letters are stored.
Words that have uncommon spellings are usually more problematic than words that follow simpler spelling patterns.
This disorder involves the loss of the ability to spell words that aren’t spelled phonetically.
Individuals with this type of agraphia can no longer spell irregular words. These are words that use the lexical spelling system rather than a phonetic spelling system.
This disorder is the inverse of lexical agraphia.
The ability to sound out a word has been damaged. To spell a word correctly, a person with phonological agraphia has to rely on memorized spellings.
People who have this disorder have less trouble writing words that have concrete meanings like fish or table, while they have a harder time writing abstract concepts such as faith and honor.
Gerstmann syndrome is comprised of four symptoms:
- finger agnosia (the inability to recognize fingers)
- right-left confusion
- acalculia (loss of the ability to perform simple number operations like adding or subtracting)
The syndrome occurs as a result of damage to the left angular gyrus, usually due to a stroke.
But it has also been associated with widespread brain damage due to conditions like:
- carbon monoxide poisoning
- excessive exposure to lead
Peripheral agraphia refers to a loss of writing abilities. While it’s caused by damage to the brain, it can mistakenly appear to be associated with motor function or visual perception.
It involves the loss of the cognitive ability to select and connect letters to form words.
Sometimes called “pure” agraphia, apraxic agraphia is the loss of writing ability when you can still read and speak.
This disorder sometimes happens when there’s a lesion or hemorrhage in the frontal lobe, parietal lobe, or temporal lobe of the brain or in the thalamus.
Researchers believe apraxic agraphia causes you to lose access to the areas of your brain that allow you to plan the movements you need to make in order to draw the shapes of letters.
When someone has visuospatial agraphia, they may not be able to keep their handwriting horizontal.
They may group word parts incorrectly (for example, writing Ia msomeb ody instead of I am somebody). Or they may confine their writing to one quadrant of the page.
In some cases, people with this type of agraphia omit letters from words or add strokes to certain letters as they write them. Visuospatial agraphia has been associated with damage to the right hemisphere of the brain.
Also called repetitive agraphia, this writing impairment causes people to repeat letters, words, or parts of words as they write.
This type of agraphia has features of aphasia (inability to use language in speech) and apraxic agraphia. It’s associated with Parkinson’s disease or damage to the frontal lobe of the brain.
Because it’s associated with writing problems related to planning, organizing, and focusing, which are considered executive tasks, this kind of writing disorder is sometimes called dysexecutive agraphia.
Rarely, a person who once knew how to write music loses that ability because of a brain injury.
In a case reported in 2000, a piano teacher who had brain surgery lost her ability to write both words and music.
Her ability to write words and sentences was eventually restored, but her ability to write melodies and rhythms didn’t recover.
What causes agraphia?
An illness or injury that affects the areas of the brain that are involved in the writing process could lead to agraphia.
Language skills are found in several areas of the dominant side of the brain (the side opposite your dominant hand), in the parietal, frontal, and temporal lobes.
The language centers in the brain have neural connections between each other that facilitate language. Damage to the language centers or to the connections between them can cause agraphia.
The most common causes for agraphia include:
When the blood supply to the language areas of your brain is interrupted by a stroke, you may lose your ability to write. Researchers have found that language disorders are a frequent result of stroke.
Traumatic brain injury
The Centers for Disease Control and Prevention (CDC) describes a traumatic brain injury as a “bump, blow, or jolt to the head that disrupts the functioning of the brain.”
Any such injury that affects the language areas of the brain, whether it arises from a fall in the shower, a car accident, or a concussion on the soccer pitch, can result in temporary or permanent agraphia.
Agraphia that gets steadily worse is, some researchers believe, one of the earliest signs of dementia.
With many types of dementia, including Alzheimer’s, people not only lose the ability to communicate clearly in writing, but they may also develop problems with reading and speech as their condition progresses.
This usually occurs due to atrophy (shrinking) of the language areas of the brain.
Less common lesions
A lesion is an area of abnormal tissue or damage within the brain. Lesions can disrupt the normal functioning of the area in which they appear.
Doctors at the Mayo Clinic attribute brain lesions to a number of causes, including:
- malformed veins
- conditions like multiple sclerosis and stroke
If a lesion occurs in an area of the brain that helps you write, agraphia could be one of the symptoms.
How is agraphia diagnosed?
Computed tomography (CT), high-resolution magnetic resonance imaging (MRI) and positron emission technology (PET) scans help doctors see damage to areas of the brain where language processing centers exist.
Sometimes the changes are subtle and cannot be detected with these tests. Your doctor may give you reading, writing, or speaking tests to determine which language processes may have been impaired by your injury.
What’s the treatment for agraphia?
In severe cases where injury to the brain is permanent, it may not be possible to fully restore someone’s previous level of writing skill.
However, there’s some research showing that when rehabilitation includes a variety of different language strategies, recovery results are better than when a single strategy is used.
One 2013 study found that writing skills improved for people who had alexia with agraphia when they had multiple treatment sessions in which they read the same text over and over until they were able to read whole words instead of letter by letter.
This reading strategy was paired with interactive spelling exercises where participants could use a spelling device to help them spot and correct their spelling errors.
Rehabilitation therapists may also use a combination of sight word drills, mnemonic devices, and anagrams to help people re-learn.
They may also use spelling and sentence-writing exercises and oral reading and spelling practice to address deficits in multiple areas at the same time.
Other researchers have had some success using drills to strengthen the connections between word sounds (phonemes) and awareness of the letters that represent sounds (graphemes).
These methods may help equip people with coping strategies, so they can function better, even when damage to the brain isn’t reversible.
The bottom line
Agraphia is the loss of a previous ability to communicate in writing. It can be caused by:
- traumatic brain injury
- health conditions such as dementia, epilepsy, or brain lesions
Most of the time, people with agraphia also experience disturbances in their ability to read and speak.
Although some types of brain damage aren’t reversible, people may be able to regain some of their writing abilities by working with therapists to re-learn how to plan, write, and spell with greater accuracy.