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Review Article | DOI: https://doi.org/10.31579/2578-8868/134
1 Psychologist sp.ing in psychotherapy with a strategic approach, Forensic Criminologist expert in sectarian cults, esoteric and security profiles, Jurist sp.ed SSPL, Essayist
*Corresponding Author: Giulio Perrotta, Psychologist sp.ing in psychotherapy with a strategic approach, Forensic Criminologist expert in sectarian cults, esoteric and security profiles, Jurist sp.ed SSPL, Essayist
Citation: Perrotta G., (2020) Agraphia: definition, clinical contexts, neurobiological profiles and clinical treatments. J. Neuroscience and Neurological Surgery. 6(4); DOI:10.31579/2578-8868/134
Copyright: © 2020 Giulio Perrotta, This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received: 17 August 2020 | Accepted: 31 August 2020 | Published: 07 September 2020
Keywords: neurobiological; neuropsychological disorder; psychotherapy
Starting from the general concept of Agraphia, the present work focuses on the clinical, neurobiological, and functional aspects of the morbid condition, suggesting a multidimensional treatment between physiotherapy, psychotherapy, and rehabilitation exercises for lost skills.
L'agraphia is an acquired neurological and neuropsychological disorder [1] that causes a loss in the ability to communicate through writing and is often associated with another neuropsychological disorder, in the area of the mechanisms involved in the form of writing (whether they are linked to language and motor deficits), such as alexia, aphasia, dysarthria, agnosia, and apraxia. [2] In summary, agraphia consists in the difficulty in producing a previously learned and known written language, with damage to various related cognitive processes, such as language processing, spelling, visual perception, visual orientation for graphic symbols, motor planning and motor control of writing). [3]
In 1553, within Thomas Wilson's book, entitled "Arte of Rhetorique", there is a trace of the first description of acquired agraphia, but only in the second half of the 19th century, the loss of the ability to produce the known written language and previously learned finally receives adequate clinical attention. In this period the idea arises that certain cortical lesions of the brain can involve a dissociation between written and spoken language, as well as altering both reading and writing skills, such as the studies of Broca and Wernicke. [12-13]
During the 1850s, Armand Trousseau and John Hughlings Jackson maintained the opinion that the same linguistic deficit occurs both in writing, both in speech and in reading, while in 1856 Louis-Victor Marcé argued the opposite: written and spoken language are independent of each other. He discovers that in many patients with language disorders, there is an impairment of both spoken language and writing. In these same patients, however, the recovery of an adequate written and spoken linguistic production does not always take place in parallel, suggesting that these two modes of expression are independent. [12-13]
Louis-Victor Marcé comes to believe that the ability to write not only involves the control of motor skills, but also the memory of signs and their meaning. Even Benedikt in 1865 comes to suggest that the areas of the brain that control writing and spoken language may have different anatomical locations, coining for the first time the clinical term, then followed in 1867 by William Ogle who laid the foundations for the first classifications nosographic, distinguishing the different dissociation models that can be found between written and spoken language. He showed that some patients with writing deficits were perfectly capable of copying the written letters, but they struggled or found it completely impossible to organize those same letters to form words of complete meaning. Ogle knew that aphasia and agraphia often occur together, but he also stressed that the deficit of the two different types of language (spoken and written) could vary in type and severity. Ogle himself distinguished between two different types of agraphia: in subjects suffering from mnemonic agraphy the written letters appeared well-formed, but often used incorrectly or completely randomly, and the words could indifferently take the place of each other; in patients with atraphic agraphia, on the other hand, the letters appeared poorly formed, intelligible and sometimes completely unrecognizable. Although Ogle's observations contributed significantly to scientific progress towards understanding writing disorders, there was still no documented case of pure agraphia. [12-13]
In 1884, Albert Pitres, strongly influenced by the modular approach to the memory of Théodule-Armand Ribot, made an important discovery by contributing to the publication of the first report of a case of pure agraphy. Pitres' reading and writing models consisted of three main components: visual (the memory for the letters and how the letters form syllables and words), auditory (the memory for the sounds represented by each letter), and motor (motor-graphic memory for letters). Based on this three-dimensional model, Pitres proposed his classification of the agraphia: a) agraphia from blindness for words: inability to copy a model, but the individual can write spontaneously and under dictation; b) agraphia from deafness for words: the inability to write under dictation, but the subject can copy a model and write spontaneously; c) motor agraphia: no ability to write, but the individual has no language deficit. [12-13]
The agraphia [1], today, is classified according to two precise forms:
"Central agraphia" [4-7] occurs when there is a deficit of spoken language and a deficit of the various motor and visualization skills involved in writing, distinguished in fluent and not fluent. In the "agraphia with fluent aphasia" (for example receptive aphasia) they normally write well-formed letters, but are unable to write significant words; those who have "agraphia with non-fluent aphasia", do not have an impairment of the spoken language and can write short sentences, but their writing is difficult to read, requires great physical effort, lacks correct syntax and often characterized by poor spelling (e.g. expressive or modifying aphasia):
"Peripheral agraphia" [3-4, 8-9] occurs when there is damage to the various motor and visualization skills that are necessarily involved in the writing activity:
Etiologically, agraphia is the consequence of a series of morbid neurological (vascular, infectious, traumatic lesions, dementia) or systemic (autoimmune and tumor) conditions that neurobiologically interfere in whole or in part with twelve brain areas associated with writing [20-27]:
The specific type of agraphia, resulting from trauma and consequent brain injury, will, therefore, depend on which area of the brain is damaged.
Very often then it is observed the writing in association with Alzheimer's disease. Writing disorders can be an early manifestation of Alzheimer's disease. The first indicative sign of involvement of the writing ability is the selective syntactic simplification of the handwriting of these patients. These patients begin to write with fewer descriptions, less detail, and complexity. Other indicators may also emerge, such as some grammatical errors. As Alzheimer's disease develops, different types of agraphia may emerge and develop. In the initial stages of the disorder, the subjects affected by it show signs of allographic agraphia and apraxic agraphy. The allographic ethic in subjects with Alzheimer's dementia is represented by the tendency to mix uppercase and lowercase in words. Egyptian Ataxia is represented by the tendency of patients to build poor, poorly constructed, or frankly illegible letters or a continuous repetition of the same traits of the letters. As the disease progresses, the severity of the writing process also progresses. Patients begin to manifest spatial agraphia, that is, the inability to write on a straight horizontal line, with the tendency to leave unnecessary spaces between letters and words. A connection between Alzheimer's disease and agraphia is the role of memory in normal writing skills. Those who can spell normally have access to a lexical spelling system that is based on a whole word: when it works correctly, it allows you to recall the spelling of a complete word, not of single letters or sounds. This system also uses an internal memory archive, where the spelling of hundreds of words is kept. This system is called a graphemic elaborate lexicon and is aptly named about the graphemic buffer, which represents the short-term memory ring for many of the functions involved in writing. When the spelling system cannot be used, for example because we are dealing with unknown words, non-words, or words whose spelling is not recognized, some people can use the phonological process called "sub-lexical spelling system". The latter system is used to probe a word and be able to write it. In individuals with Alzheimer's disease, the memory stores that are used for everyday writing are lost as the disease progresses. [14]
From a rehabilitative point of view, agraphia cannot be treated directly, but individuals affected by it can be rehabilitated to regain some of their previous writing skills: in the absence of neurological symptoms of another nature, such as amnesia [15], epilepsies [16] or dementia [14, 17-18], the techniques of memorization of keywords, the use of technology for word processing, manual writing, artistic and abstract drawing and physiotherapy are extremely functional, combining a targeted psychological therapy for cognitive-behavioral or strategic support [19].