- 5.4. Sensory Forms of Agraphia: The Impairment and Restoration

Lecture

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and texts, b) independently breaking the word into parts and writing it down first in parts, then as a whole, and others.

Work on the restoration of the writing of phrases and texts proceeds by the same method. This method is described in more detail by us in other works.

These same impairments of writing are often encountered in younger (and even in older) schoolchildren. In this case as well it is necessary to work on expanding the span of acoustic perception and on translating the successive form of perception into a simultaneous one. The method described above is the most adequate here as well. The second direction of restorative instruction provides for work on restoring object images-representations, symbolic images, and their connection with the word (the letter, the phrase, the text). (FOOTNOTE: Tsvetkova L. S. Neuropsychological Rehabilitation of Patients. Moscow: Moscow State University Press, 1985; Tsvetkova L. S. Aphasia and Restorative Learning. Moscow: Moscow State University Press, 1988).

There are two more forms of agraphia that occur within the syndrome of speech disturbances. These are forms of agraphia in which writing is impaired as written speech even more than in the form described above, which is nonetheless still linked to impairment of the sensory conditions of the course of writing (the narrowing of the span of perception). The dynamic and semantic forms of agraphia, occurring within the syndrome of the corresponding forms of aphasia, have no relation to impairment of the sensorimotor or motor mechanisms of writing. In these forms of agraphia, written speech is impaired as a means of expressing thought, and these agraphias are formed when the very highest levels in the organization of written speech are impaired.

In dynamic agraphia, the central mechanism is impairment of inner speech, of general and verbal predicativity. These mechanisms lead to impairment of activity in creating the structure of the phrase, of its dynamics, and of their interaction in the structure of the text. Impairments of written speech in this case appear as part of the syndrome of general psychological motor and intellectual inactivity, inactivity of the personality and, as a whole, of psychological activity. The central defect is impairment of the actualization and construction of the structure of the phrase, impairment of the order governing the agreement of words within the phrase and of phrases within the text. In the case of semantic agraphia we are likewise dealing with impairment of a high level of organization of writing: here difficulties arise in using certain complex logico-grammatical constructions (the use of prepositions, comparative constructions, constructions with complex subordinate clauses, and others).

In both cases as well, independent tasks of restorative instruction arise, and methods of instruction adequate to the structure of the defect are applied. It would be incorrect to think that these forms of impairment of writing will be eliminated on their own, as soon as success appears in the restoration of oral speech. Of course, the restoration of writing here depends on the restoration of oral speech, but only within certain limits. This will become understandable if we recall that the structure of oral and of written utterance differ sharply from one another, since written speech is always monological, whereas oral speech is most often dialogical, and all the more so in patients in the course of speech instruction.

Patients with dynamic agraphia are taught how to draw up a plan for a summary (composition), are taught the ability to construct written sentences — long compound and complex sentences, sentences with distant word order, impersonal sentences, and others, and to carry out a conscious analysis of the structure of the sentence, of errors, and so on.

Patients with semantic agraphia are first taught to write short, simple sentences, with their subsequent transformation into complex ones.

Thus, as can be seen from the analysis, impairments of writing almost always accompany aphasia. Depending on the nature of the aphasic syndrome, different mechanisms may underlie the impairment of writing, manifesting themselves either in the disintegration of the auditory image of the word, or in a defect of the sound-articulation schemes, or in impairment of the awareness of the sequence of sounds in the word, or in impairment of the dynamic successive structure of the sentence and of the whole text. However, the clinical picture of agraphia extends beyond impairments of writing connected only with speech disturbances. Agraphia extends to the occipital and parieto-occipital systems of the left hemisphere and enters into the syndrome not of speech disturbances any longer, but of optical, optico-mnestic, or spatial disturbances (A.R. Luria, O.P. Kaufman, B.G. Ananyev, and others).