NOTE
PURE DYSGRAPHIA WITH RELATIVE SPARING OF
LOWER-CASE WRITING
Luigi Trojano and Laura Chiacchio
("Clinica del Lavoro" Foundation, IRCCS, Medical Center of Rehabilitation, Campoli
Monte Taburno, Italy; Second Department of Neurology, School of Medicine, "Federico
II" University, Naples, Italy)

INTRODUCTION

Since the early 1980s writing disorders have been studied within information processing
frameworks. Cognitive analyses of dysgraphia have often been based upon models of writing
that propose some "central" linguistic processes and some "peripheral" processes related to
the actual motor output and specific for written output (Ellis, 1982; Margolin, 1984).
It has been proposed that at the end of the "central" spelling routes a short-term retention
buffer is aimed at storing orthographic representations of words and nonwords alike, before
the actual realization of output. This so-called Graphemic Output (orthographic) Buffer (GOB)
would also be implied in oral spelling. Beyond the graphemic buffer, "peripheral" processes
are devoted to transforming the orthographic string into graphic motor programs specifying
the sequences of movements necessary for handwriting. A specific impairment of the GOB
would imply quantitatively and qualitatively similar graphemic errors in all writing tasks
(delayed copy, naming, writing to dictation) and in oral spelling. In fact, such a pattern has
been reported in the literature (Caramazza, Miceli, Villa et aI., 1987; Posteraro, Zinelli and
Mazzucchi, 1988; Hillis and Caramazza, 1989; Caramazza and Miceli, 1990).
Diagnostic criteria for selective impairments of the GOB can be summarized as follows
(Hillis and Caramazza, 1989): (1) similar patterns of spelling errors for words and nonwords;
(2) number of errors increasing as a function of item length; (3) no effect of lexical factors;
(4) no semantic or morphological errors; (5) spelling errors consisting of deletions, insertions,
substitutions and transposition of letters which may lead to the production of graphemically
implausible nonwords.
Recently, some detailed observations have also been reported upon deficits of "peripheral"
processes in handwriting (e.g., Baxter and Warrington, 1986; Papagno, 1992). Some of these
patients, whose oral spelling was always correct, showed double dissociations between lowerand upper-case handwriting style (De Bastiani and Barry, 1986; Patterson and Wing, 1989;
Kartsounis, 1992). In these cases, it was postulated that the selective impairment occurred
in "peripheral" writing processes, where lower- and upper-cases style can be represented by
independent graphic motor codes.
In the present paper we describe a patient affected by acquired pure dysgraphia with a
relative sparing of lower-case writing. In this case the dissociation between upper- and lowercase writing does not seem related to defects in "peripheral" writing processes.
CASE REPORT

D.V.M. was a 72-year-old right-handed housewife with 7 years of education. Her native
language was Italian. In June 1991, she sustained a left ischemic cerebral lesion whose clinical
signs were a right homonimous hemianopia and slight weakness of right arm. CT scan showed
a left parietal-occipital ischemic lesion, with enlargement of left occipital ventricular horn
(Figure 1). Doppler fluxirnetry showed marked stenosis of left common carotid artery. D.V.M.
Cortex, (1994) 30, 499-507

500

L. Trojano and L. Chiacchio

Fig. 1 - CT scan.

complained of mild amnesic and moderate writing disturbances. She was evaluated from
October to December 1991. She was well-oriented and cooperative. The patient was given
some neuropsychological tests from a standardized Italian battery (Spinnler and Tognoni,
1987). Immediate verbal memory (Bysillabic word span=4), memory for complex verbal
material (Story test = 10.3/16), constructional, oral and limb praxis were in the normal range
for age and education. She obtained a poor score at Corsi' s visuospatial immediate memory
task (3). Her Verbal I.Q. was in normal range (95).
Speech-language Evaluation

D.V.M. did not show overt aphasic disturbances. She performed flawlessly on tasks for
spontaneous speech and naming, oral and written comprehension, repetition and reading aloud,
comprised in an Italian standardized battery (Basso, Capitani and Vignolo, 1979). She could

TABLE I

Written Tasks of Standard Battery (scores expressed in percentages)

Written naming
Writing to dictation
Letters (10)
Syllables (10)
Words (10)
Nonwords (5)
Sentences (5)

Lower-case

Upper-case

85

40

100
100

100
100

80

40
40

Word copy (10)

80

60

Letter transposition
Upper- to Lower-case (21)
Lower- to Upper-case* (21)

100

* This task is not comprised in the battery.

60
40

o

100

Lower-case sparing in dysgraphia

501

A)

B)

Fig. 2 - Examples of D. V.M.' s upper- and lower-case writing: A) delayed copy ("novembre" november - written as "noverbe" in upper-case and correctly in lower-case); B) writing to dictation
("fratello" - brother - written as "frtello" in upper-case and correctly in lower-case).

sign her name but made many errors in writing tasks, and she reported more difficulties
when writing upper-case letters. For example, when asked to write a letter to her husband,
she managed to write two sentences in lower-case script, but refused to write in upper-case.
For this reason, we asked her to perform standard writing tasks both in lower- and uppercase format. Results are shown in Table I.
D.V.M. wrote single letters and CV syllables without errors, and correctly transposed
single letters from upper-case to lower-case and viceversa. By contrast, she made many errors
in copying and in writing words and nonwords spontaneously and to dictation, with a better
performance with lower-case format (Figure 2).
This picture suggested that D.V.M.'s impairment was neither in the selection nor in the
actual motor output of single letters, but in the production of letter strings, especially in
upper-case.

502

L. Trojano and L. Chiacchio
TABLE II

Correct Responses at Writing to Dictation and Spelling
Lowercase

Uppercase

Spelling

27

17

10

Nouns (10)
Verbs (10)
Functors (10)

10
8
9

7
5
5

5
2
3

Bisyllabic (15)
Trisyllabic (15)

14
13

9
8

9
1

21

18
14 .
2
2

19

Words (30)

Nonwords (25)
Monosyllabic (15)
Bisyllabic (5)
Trisyllabic (5)

15
3
3

15
3
1

Special Writing Evaluation

In order to investigate D.V.M.'s difficulties in detail, we compared lower- and uppercase writing in several tasks (writing to dictation, copying and written naming) on different
lists of words and nonwords. In particular, we tried to confirm discrepancies between lowerand upper-case writing and to identify the source of her spelling disorder. Part of the material
used in this study was taken from an Italian battery for the cognitive analysis of language
disorders (Miceli, Laudanna and Burani, 1990).
Test 1: Word and Nonword Writing to Dictation and Oral Spelling

The patient was presented with a list of 30 words, balanced for length and grammatical
class, and with a list of 25 pronounceable nonwords, 2- to 8-letter long. During the same
session, the patient first wrote the list in lower-case format, then in upper-case and finally
she was asked to spell item orally. Results are given in Table II.
D.V.M. spelled words in lower-case significantly better than in the other modalities tested
(X 2 = 20, d.f. = 2, P = 0.(01). Upper-case writing and oral spelling did not differ from each
other (X 2 =3.3, d.f.= 1, p=0.7), although the patient made more errors during spelling.
Grammatical class did not affect either upper-case writing or spelling, while spelling showed
a clear effect of stimulus-length (D.V.M. spelled correctly only one long word).
The few lower-case errors were single graphemic errors (1 insertion and 1 deletion) and
one double error (l deletion + 1 substitution), all resulting in nonwords. In upper-case writing
and oral spelling, errors consisted of single or multiple letter deletions, substitutions, insertions
and transpositions. Responses resulted in pronounceable and non pronounceable nonwords.
One deletion in oral spelling resulted in a real word ("puniti" - punished - was spelled as
"punti" - points).
In nonwords writing, D.V.M. showed a similar accuracy in all three spelling tasks (X2= 1,
dJ. = 2, P = 0.5). She made only 1 error with 2-letter items (in upper-case writing) but
produced many errors with longer stimuli: length had a significant effect in all tasks (X 2 = 7.2,
8.4 and 14 for lower-, upper-case and spelling, dJ. = 2, p<0.02, 0.01, and 0.001 respectively).
Also with nonwords, D.V.M.'s errors in all spelling tasks consisted of single and (rarely)
multiple graphemic errors (mainly substitutions and deletions) resulting in pronounceable
and nonpronounceable nonwords. A quantitative error analysis will be reported below.
Test 2: Word and Nonword Writing to Dictation and Copying

The patient was asked to write to dictation in lower- and upper-case, and to copy from
the model in upper-case letters a list of 30 words, balanced for frequency and length, and
30 nonwords, balanced for length. D.V.M. read all stimuli flawlessly. Results are given in

Lower-case sparing in dysgraphia

503

TABLE III

Correct Responses at Word and Nonword Writing to Dictation and Copy
Lowercase

Uppercase

Copy

Words (30)
High-Frequency (15)
Low-Frequency (15)
4-1etter (6)
5-1etter (6)
6-1etter (6)
7-1etter (6)
8-1etter (6)

29
15
14
6
6
5
6
6

17
7
10
6
4
3
3
1

21
10

Nonwords (30)
4-1etter (6)
5-1etter (6)
6-1etter (6)
7-1etter (6)
8-letter (6)

22
5
5
5
5
2

16
5
4
4
2
1

23
6
6
5
3
3

11

6
6
4
4
1

Table III. The first relevant finding is that D.V.M.'s accuracy in upper-case copying was
similar to that observed in upper-case writing to dictation. Moreover, D.V.M. made only
one error in lower-case word writing to dictation. Performance on this task was significantly
better than that on upper-case writing (X 2 = 13.4, dJ. = 1, P = 0.0002). Very good performance
on lower-case spelling prevented the study of frequency and length. Upper-case writing
(X2= IO.S, dJ. =4, P =0.03) and copy (X2= 14.S, dJ. =4, p<O.OOS) were significantly affected
by stimulus length, but not by word frequency (upper-case writing: ~2=1.2, dJ.=l, p=0.2).
In non word writing, accuracy did not differ significantly (X = 2.S, d.f. = 1, P = 0.1)
between lower- and upper-case format. Again, D.V.M.'s performance was poorer on longer
items, but not significantly so for the three modalities tested.
Lower-case word writing to dictation was significantly better than nonword writing
(X 2 = 6.4, d.f. = 1, p<O.Ol), while neither upper-case writing nor copying differed for words
and nonwords.
In lower-case word writing D.V.M. made only one literal substitution that gave rise to
a nonpronounceable word ("membri" - members - written as "membni"). With nonwords,
lower-case errors were predominantly letter substitutions resulting in some words, and in
legal and illegal nonwords. Errors in upper-case writing and copying were similar for words
and nonwords (single or multiple letter deletions, substitutions, insertions and transpositions).
Responses in upper-case nonword writing and copying consisted mainly in (pronounceable
or illegal) nonwords; only one response was a real word ("came" written as "cane" - dog).
Test 3: Delayed Copying

We asked D.V.M. to copy in lower-case stimuli written in upper-case and viceversa. We
used 10 non words and 10 words, of different length, to be copied after an unfilled to-sec
interval. D.V.M. made no errors when copying in lower-case format. In upper-case copying,
she achieved similar scores for words (6/10) and nonwords (S/10). Performance was affected
by length (words: 8S% correct for short stimuli versus 2S% correct for long stim~li; nonwords:
7S% versus 33%). Errors were similar to those observed in the other tasks.
Test 4: Written Naming

The patient was presented with two sets of line drawings: the first comprised 22 objects
whose names were balanced for length and frequency, the second comprised 22 actions
balanced for frequency. She was asked to write each list in lower-case first and then in
upper-case.

L. Trojano and L. Chiacchio

504

TABLE IV

Error in Lower- and Upper-case Handwriting and in Oral Spelling
Lower-case

Upper-case

Oral spelling

Words

Nonwords

Words

Nonwords

Words

Nonwords

Total
121114
Single graphemic errors 8 (67%)
Insertions
2
Deletions
3
Transpositions
0
Substitutions
3
Multiple
graphemic 4 (33%)
errors

12/55
10 (83%)
1
2
0
7
2 (17%)

651144
47 (72%)
8
15
6
18
18(28%)

33/85
23 (70%)
2
7
3
11
10 (30%)

22/30
14 (66%)
0
7
5
2
7 (33%)

6125
4 (66%)
0
2
1
1
2 (33%)

5 (42%)
6 (50%)
1 (8%)
0

0
49 (75%)
16 (25%)
0

1 (3%)
26 (79%)
6 (18%)
0

1 (4%)
11 (52%)
9 (42%)
1 (4%)

0
4 (66%)
2 (33%)
0

Responses consisting in:
Words
Nonwords
Illegal
Refusals

0
9 (75%)
3 (25%)
0

Accuracy was similar for objects and actions. Once more, lower-case spelling was
significantly better than upper-case writing in both object (86% versus 40%; X2 = 9.9, dJ. "= 1,
p=O.OOl) and action naming (77% versus 40%; X2 =7.5, d.f.= 1, p=0.006). In lower-case
writing, the effect of frequency was significant when object and action naming were
considered together (95% correct for high-frequency items versus 40%; X2 = 5.8, dJ. = 1,
P = 0.01), while length had no effect (X 2 = l.3, d.f. = 1, P = 0.2). By contrast, upper-case
writing was significantly affected by stimulus length (57% correct for short words versus
12%; X2 =4.1, d.f.= 1, p=0.04), but not by word frequency.
Errors were graphemic in nature in both lower- and upper-case writing (mainly
substitutions and deletions, but also insertions and transpositions) and responses resulted in
pronounceable and nonpronounceable nonwords.
Error Analysis

D.V.M. showed a peculiar writing pattern. She showed similar numbers of errors in
upper-case writing to dictation, copying and naming, and in oral spelling, with similar
performance on words and nonwords. On the other hand, lower-case writing was more
accurate for familiar stimuli (words versus nonwords; high-frequency versus low-frequency
words), while item length did not affect word writing. These observations could suggest that
lower- and upper-case writing relied upon different mechanisms. However, D.V.M. produced
similar graphemic errors in lower- and upper-case handwriting and in oral spelling, as shown
by the cumulative analysis of errors in all the tasks (Table IV).
The few lower-case errors on words demonstrated the same distribution as upper-case
errors: they were represented mainly by single graphemic deletions or substitutions, resulting
in legal or illegal nonwords. In lower-case writing of nonwords, D.V.M. produced a large
number of single graphemic substitutions, often resulting in real words (5/12 errors; e.g.
"sterso" became "sterzo" - steering wheel). In oral spelling the error pattern was similar,
although insertions were absent and deletions were very frequent. The distribution of spelling
errors as a function of letter position also showed relevant findings. Cumulating words and
nonwords processing tasks, which shared the same features, errors were most frequent in
the relative medial position in all modalities (Figure 3).
These findings demonstrate that errors in lower- and upper-case handwriting and in oral
spelling not only were similar but also respected the same spatial distribution. Thus, the
source of errors was very likely to be the same.

Lower-case sparing in dysgraphia

505

0,5
0,4
0,3
Q)

...'"c:

Ol
Q)

u
....

0,2

~

Lower-case

•

Upper-case

•

Oral spelling

Q)

a..

0,1
0,0

2

3

4

5

Relative letter positions

Fig. 3 - Incidence of errors as a function of relative letter position (computed according to Wing
and Baddeley, 1980).
DISCUSSION

A selective impairment of lower- or upper-case handwriting, due to a selective damage
of peripheral writing processes, has been reported in a few patients with difficulties in letter
formation and unimpaired oral spelling (Patterson and Wing, 1990; Kartsounis, 1992).
Our patient did not present difficulty in retrieving the correct motor programs when writing
single letters or longer strings: letters were clearly legible and easily identifiable on all
occasions. We did not perform a systematic temporal analysis of written output (as suggested
by Patterson and Wing, 1990). However, our patient appeared to spend comparable times
in tracing lower- and upper-case letters, without relevant hesitation. D.V.M. repeatedly
declared that she preferred lower-case writing because she was more familiar with it and
especially because she was aware of the greater number of errors in upper-case writing. She
often became aware of her errors either while she was writing her responses or after
completing them. Then, she repeated the stimulus accurately, but corrected written responses
only occasionally.
The lack of alterations of letter formation and the impairment of oral spelling ruled out
a "peripheral" account for this patient's defect. Instead, D.V.M.'s writing pattern suggested
an interaction of central and peripheral writing processes: lower-case writing was relatively
preserved, although a single cognitive impairment likely induced equivalent errors in the
three modalities (lower-, upper-case and oral spelling).
D.V.M.'s upper-case writing showed qualitatively and quantitatively similar errors in
writing to dictation, copying and confrontation naming. Lexical status of items did not affect
performance; word and nonword copying were impaired as well; errors were always
graphemic in nature and were a function of item length with a higher incidence in central
positions. Oral spelling showed a qualitatively and quantitatively similar error pattern.
Thus, D.V.M.'s functional impairment appeared to be restricted to a component devoted
to processing graphemic representations, independent of input modality, common to oral and
written spelling, and shared by lexical and phonological mechanisms. These findings met
the criteria outlined in the introduction for a GOB defect.
In the present case the GOB impairment would not result in a limited retention of
information (Katz, 1991), nor would it be affected by attentional gradients (Hillis and
Caramazza, 1989). D.V.M., as well as normal subjects (Wing and Baddeley, 1980), produced
most errors in the medial position of letter strings, a pattern typical of patients with GOB
impairments (Caramazza et aI., 1987; Posteraro et aI., 1988).
A GOB defect should not imply differences between lower-case and upper-case

506

L. Trojano and L. Chiacchio

handwriting because graphemic representation held in this post-lexical buffer are then treated
in (he same way. This- assumption has not been tested specifically in other patients: some
authors compared handwriting and typing, without relevant differences (Miceli, Silveri and
Caramazza, 1985), while others studied only one response modality (e.g., Posteraro et aI.,
1988). The fact that D.V.M. was more accurate in writing familiar words in lower-case
would be inconsistent with a GOB impairment. However, our analysis showed that the error
pattern in lower-case script was similar to that observed ·in the two other modalities, and
matched that expected in GOB defects on qualitative grounds. So, available data suggested
that the GOB was the source of graphemic errors in all tasks, but that it was involved to
a different extent in different output modalities. To account for the lexical facilitation in
lower-case, one could assume that D.V.M. relied less on the GOB when spelling in lowercase because this is a simple and more automatized task.
In conclusion, D.V.M. showed a previously unreported writing pattern. Even though
lower-case writing of familiar stimuli was relatively spared, errors showed a similar
distribution across tasks. We suggest that a GOB defect could account for such findings,
because lower-case word writing posed a minimum load on the buffer. Although admittedly
ad-hoc, such an interpretation raises the issue of the equivalence of different handwriting
styles, suggesting possible interactions of central and peripheral writing processes. Systematic
investigations of performance on different spelling tasks in dysgraphic patients are necessary
for addressing these theoretical aspects of writing models.
ABSTRACT

We describe the cogmtIve analysis of a patient with acquired pure dysgraphia. She
presented a peculiar dissociation between lower- and upper-case handwriting: lower-case
writing was relatively spared and showed a significant superiority of words versus non words.
Upper-case writing and oral spelling did not show lexical effects, but were affected by item
length. In all modalities errors consisted mainly of single graphemic substitutions, deletions,
insertions and transpositions, resulting in legal or illegal nonwords, and showed a similar
distribution across letter positions. These findings were suggestive of an impairment of the
graphemic output buffer, which however revealed itself to different degrees in the two
handwriting styles.
Acknowledgements. We would like to thank G. Miceli and D. Grossi for their helpful
comments on the manuscript.
REFERENCES
BAsso, A., CAPITAN I, E., and VIGNOLO, L.A. Influence of rehabilitation on language skills in aphasic
patients. A controlled study. Archives of Neurology, 36: 190-196, 1979.
BAXTER, D.M., and WARRINGTON, E.K. Ideational agraphia: a single case study. Journal of Neurology,
Neurosurgery and Psychiatry, 49: 369-374, 1986.
CARAMAZZA, A., and MICELI, G. The structure of graphemic representations. Cognition, 37: 243-297,
1990.
CARAMAZZA, A., MICELI, G., VILLA, G., and ROMANI, C. The role of the graphemic buffer in spelling:
evidence from a case of acquired dysgraphia. Cognition, 26: 59-85, 1987.
DE BASTIANI, P., and BARRY, C. After the graphemic buffer: Disorders of peripheral aspects of writing
in an Italian patient. Paper presented to the joint meeting of Experimental Psychology Society and
the Societa Italiana di Neuropsicologia, Padua, April 1986.
ELLIS, A.W. Spelling and writing (and reading and speaking). In A.W. Ellis (Ed.), Normality and
Pathology in Cognitive Functions. London: Academic Press, 1982.
HILLIS, A.E., and CARAMAZZA, A. The graphemic buffer and attentional mechanisms. Brain and
LAnguage, 36: 208-235, 1989.
KARTsouNIS, L.D. Selective lower-case letter ideational dysgraphia. Cortex, 28: 145-150, 1992.
KATZ, R.B. Limited retention of information in the graphemic buffer. Cortex, 27: 111-119, 1991.
MARGOLIN, D.1. The neuropsychology of writing and spelling: Semantic, phonological, motor and
perceptual processes. Quarterly Journal of Experimental Psychology, 36A: 459-489, 1984.

Lower-case sparing in dysgraphia

507

MICELI, G" LAUDANNA, A., and BURANI, C. Batteria per l'analisi dei deficit afasici. Milano:
Associazione per 10 Sviluppo delle Ricerche Neuropsicologiche, 1990.
MICELI, G., SILVERI, M.e., and CARAMAZZA, A. Cognitive analysis of a case of pure dysgraphia. Brain
and Language, 25: 187-212, 1985.
NOLAN, K.A., and CARAMAZZA, A. An analysis of writing in a case of deep dyslexia. Brain and
Language, 20: 305-328, 1983.
PAPAGNO, e. A case of peripheral dysgraphia. Cognitive Neuropsychology, 9: 259-270, 1992.
PATTERSON, K., and WING, A.N. Processes in handwriting: A case for case. Cognitive Neuropsychology,
6: 1-23, 1989.
POSTERARO, L., ZINELLI, P., and MAZZUCCHI, A. Selective impairment of the graphemic buffer in
acquired dysgraphia. Brain and Language, 35: 274-286, 1988.
SPINNLER, H., and TOGNONI, G. Standardizzazione e taratura italiana di test neuropsicologici. Italian
Journal of Neurological Sciences, Suppl. 8, 1987.
WING, A.M., and BADDELEY, A.D.Spelling errors in hand writing: A corpus and a distributional analysis.
In U. Frith (Ed.), Cognitive Processes in Spelling. New YorklLondon: Academic Press, 1980.

Luigi Trojano. Fondazione Clinica del Lavoro. Centro di Campoli M.T., 82030 Campoli (BN), Italy.