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Increased Writing Activity Inneurological Conditions: a Review 51051ournal ofNeurology, Neurosurgery, and Psychiatry 1996;61:510-514 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.61.5.510 on 1 November 1996. Downloaded from SHORT REPORT Increased writing activity in neurological conditions: a review and clinical study P van Vugt, P Paquier, L Kees, P Cras Abstract of behaviour and that similar increased writing Increased writing activity in a 70 year old, activities have been labelled differently. We right handed man presenting with a his- would like to clear up the terminological con- tory of alcohol misuse and maturity onset fusion in the literature on increased writing diabetes is reported. Brain CT disclosed activity by reporting another patient and by corticosubcortical atrophy and 99mTc- differentiating automatic writing behaviour HMPAO SPECT disclosed severe bilat- from hypergraphia. eral frontal hypoperfusion more prominent on the right. The patient's neuropsychological symptomatology con- Case report sisted of severe (verbal) aspontaneity, A 70 year old right handed man with a long intermittent utilisation behaviour, and history of alcohol and tobacco misuse and a pronounced increased writing activity, previous medical history of well controlled which mainly consisted of a persevera- non-insulin dependent diabetes mellitus was tive, micrographic written reproduction admitted after a fall causing a left orbitomaxil- of visually or verbally perceived language lar fracture. He had been drinking several fragments. Several neurological causes of beers a day for many years and had shown increased writing activity and the equivo- progressive memory disturbances during the cal terminology met in the medical litera- year before admission. Relatives reported dys- ture are reviewed. A distinction between praxic behaviour, decreased verbal output, hypergraphia and automatic writing and two fugue episodes. Clinical examination behaviour is proposed. It is concluded on admission showed a frail, apathetic old that our patient's increased writing activ- man who was disoriented in time and space. ity may be characterised as automatic His liver was slightly enlarged. There was no writing behaviour. tremor and no asterixis. He displayed bilateral grasping, and there was a clear bilateral pal- http://jnnp.bmj.com/ (3 Neurol Neurosurg Psychiatry 1996;61:510-514) momental reflex. During his stay in hospital the patient remained aspontaneous. Only rarely did he respond, with one or two words, Keywords: frontal lobe; hypergraphia; compulsive adequately answering the question. He walked writing Unit of with a wide base and there was bilateral Neurolinguistics, reduced diadochokinesia. However, there was University of Antwerp Increased writing activity in mental illness is a no ataxia nor dysmetria. on September 25, 2021 by guest. Protected copyright. (UIA), Belgium P van Vugt well accepted topic of interest.'2 On the other Laboratory tests showed slightly raised L Kees hand, abnormal writing behaviour resulting ammonia (up to 66 mg/100 ml). Hepatic Department of ENT from neurological disorder is seldom reported. enzymes were normal, except for gGT which Surgery, University of Probably the best known example is the ictal3 was slightly raised. Chest radiography, urine, Antwerp (UIA) and Department of or interictal increased writing activity seen in thyroid function, serology (for Treponema pal- Neurology, University some patients with temporal lobe epilepsy.' 4 5 6 lidum, HIV), uric acid, lipids, vitamin B 12, Hospital Erasme However, its frequency and specificity in tem- and CSF tests were negative or normal. His (ULB), Belgium poral lobe epilepsy4 have been questioned: EEG showed theta waves in the occipital P Paquier increased writing activity has also been lobes. Brain CT disclosed pronounced, gener- Department of Neurology (Born- described in mentally retarded patients alised corticosubcortical atrophy and ventricu- Bunge Foundation), (epileptic and non-epileptic)7 and in patients lomegaly more prominent on the right. As University of Antwerp with brain tumours,"9 cerebral strokes,'0 multi- normal pressure hydrocephalus was suspected (UIA), Belgium P Cras ple sclerosis,"I or frontal lobe dementia.'2 Omnipaqueg was injected intrathecally. In the past, increased has The of CSF was normal. 99mTc- Correspondence to: writing activity resorption Dr P van Vugt, Unit of been referred to as hypergraphia,' echo- HMPAO SPECT showed severe frontal Neurolinguistics, CBL-UIA, on Universiteitsplein 1, B-2610 graphia, graphomania,8 anosognosic graph- hypoperfusion, more pronounced the right Wilrijk, Belgium. omimia, 4 graphorrh6e,'5 and phonographie.'6 (fig 1). Received 22 November 1995 Although diagnostic criteria have been pro- The mini mental state examination22 was and in final revised form 3 July 1996 posed,'4 '7 a comparative study of case reports difficult to evaluate due to the lack of commu- Accepted 4 July 1996 shows that one term may cover different types nication, but the patient scored 11/30 at his Increased wniting activity in neurological conditions: a review and clinical study 511 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.61.5.510 on 1 November 1996. Downloaded from L- F,:--, 4Aol TrRANst)5EF::=E -S I : n tv yq - v A.r-;i-. t.. ~~~~~~~~~~~~~~~~~~~~iI =1 6-- :i Figurel1 99mTc-HMPAO SPECT images show severefrontal hypoperfsion,more pronounced on the right. best. Psychiatric examination showed some care was taken to replace the ballpoint pen loss of decorum. The patient did not confabu- used the day before by a differently coloured late. There was no obsessive compulsive per- one. To observe the patient's communicative =~~~~~~~~sonality disorder and during clinical bedside reaction when confronted with unexpected examination no obsessional traits were found. written stimuli, we surreptitiously inserted On the ward he displayed a mild form of utili- questions about his youth, his family, the hos- http://jnnp.bmj.com/ sation behaviour and a pronounced increased pital food, etc in the otherwise blank note- writing activity. book. Instructions related to writing as well as During an observation period of five weeks, geometric figures alternated with these ques- the patient produced 22 925 written words. tions, as we wanted to assess the patient's abil- The writing was micrographic but legible (fig ity to adapt his behavioural pattern and the 2). Generally, the patient copied whatever he degree to which the imitation was servile set his eyes on: a newspaper headline, the (table). on September 25, 2021 by guest. Protected copyright. instructions on the television set, the trade The differences in ink disclosed that during mark on his pencil. He went on copying until the observation period the patient wrote three the end of the page or until another visual to four pages a day. He tended to fill all the stimulus caught his eye (table). The copying space available on the pages, and would often was rather careless: punctuation, numbers, return to previous pages to fill up the margins and abbreviations were not always respected, horizontally and vertically. Except for one conjunctions were often added (and ... and ... instance of shadow copying, small as well as and), prepositions were substituted. The large geometric patterns were disregarded and intrusion of neologisms suggested lexical wan- simply covered with text. Horizontal lines did dering (for example, de eeuwige achtervelden, not influence the writing activity, whereas ver- the happy backing grounds). As he became tical lines seem to have been perceived and more distracted during the act of writing, he respected as margins, or at least as an element would insert questions asked to him or a sen- organising writing space. Usually, questions tence overheard in a conversation. As a result, and instructions were copied several times. the text sometimes became very awkward and Occasionally a semantically related one word difficult to understand. or one syntagma response was formulated and The patient's writing activity was closely repeated over and over again. More than once, monitored during weeks 2 and 3. The nursing the copied instruction was personalised-for staff made sure that the patient only had a example, "You must not write here" became notebook at his disposal and every morning "I must not write here". 512 van Vugt, Paquier, Kees, Cras J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.61.5.510 on 1 November 1996. Downloaded from 2 'JI a a §4W44<Cg>GA%410, t2 -4- -'~~~~.s~ -~~~~~~~~~~~~ cO a1) *_ 0 N- 0 0~~~~~~~~~~~~~~~ 4-J 't -T X CC -jziDX*10 j4/4>dS<AtA44%tso1m4t1 CD o 4 Ii:~~~~~~~: http://jnnp.bmj.com/ V~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~4 on September 25, 2021 by guest. Protected copyright. ~~~~~~~~~~~~~~~+-D~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~- C Q +1 9I Aj--~~. '- -4a1~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~'0-'- ViV ~ I_q a -3 44 -. 4- 0-. Increased writing activity in neurological conditions: a review and clinical study 513 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.61.5.510 on 1 November 1996. Downloaded from Some examples ofinstructions and stimuli randomly inserted in a blank DINAS notebook, and description of the patient's graphic response Instruction or stimulus Spatial display Patient's response Write the word steam engine See fig 2A The word is initially copied four times. Later on, the three times in the box patient wrote the word another five times in the box. Finally, the page is covered with the word. Copy below the following Printed at 130 mm The sentence is copied once. The next day we found sentence once from the top out that the same sentence had been used to cover the entire page as well as the next two pages. Do not write on this side of Printed in a 60 mm wide The ban is copied on the right side of the line; afterwards, the line margin, see fig 2B the patient fills up the restricted area. Do you like the food? Printed at the page centre Unrelated page covering writing, until the question is reached. Below the question is answered 64 times: "Yes, very much". Diamond 140 x 90 mm Page centred The patient keeps on writing straight across the geometric figure.
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