What does insanity feel like?

What does quiet insanity feel like? It feels just awful! It is Unbearable even!  Kraepelin’s patients reported this to him. Paula reported this to me. She was only able to express why it was so bad once she recovered.
 An attack of depressive insanity feels like a state of extreme internal arousal and agitation.  .Paula still remembers; It involved a high level of inexplicable unpleasant physical distress. The onset was abrupt,  woke her up from sleep and lasted over a year. Paula also felt a strangely unbearable sense of stiffness, everywhere.  Depressive insanity is impossible to describe, much the same as pain . If you have never experienced this, [ and we hope you never do], then you won’t relate. 
The dread, distress and arousal is ongoing, chronic, and it blocked all other sensations. It blocked sensations of hunger, thirst, or needing to go to the bathroom. It interfered with thinking, memory, intellect, comprehension, and speech.  The sensations of dread, distress, stiffness and high arousal/fear consumed Paula every minute. It made it very hard to sleep.  It was a nightmare.
What looks externally like a depressed and quiet-  almost zombie-like state is paradoxically the polar opposite. It is, in fact a state of extreme internal arousal and distress.
I remember when Paula fell ill.I never guessed that she was in physical distress.  I only saw the body language that suggested defeat, sadness, and depression. The stiffness of her fear, I thought was anger [ at me]. Her mask like unsmiling face, again seemed like expressions of anger or unhappiness with me or with her world.
This is interesting,  because if you think of it, because the nonverbal expression of illness or fatigue is similar to that we call depression.  Infection and depression can cause loss of appetite, difficulty sleeping, loosing weight, being more silent then usual, looking pale,looking unhappy, etc…These are, after all non specific signs that occur in a number of states.  We depend on the person to tell us what is happening with them to explain these changes in posture and behaviour and the rest.
But what if they can’t? That is when mistakes are made, when misunderstandings occur.
 Paula could not explain what was happening to her because she  suddenly could not communicate; she couldn’t think properly and she physically couldn’t form speech easily. She couldn’t breathe normally either but she did not know it. [This is because she didn’t breathe normally in health and she didn’t feel that either]. 
She felt the dread of near suffocation, yet did not recognize the sensation of difficulty breathing. Neither did she show the classic signs of a person in breathing difficulty. She looked instead, a little like a stiff statue with a mask like face. It was disturbing to see her like that.
 It seemed paradoxical…that a person could move and talk so little, yet be silently and confusedly distressed internally,…it seemed paradoxical, until someone measured the person’s vital signs; respiratory rate,heart rate, blood pressure, body temperature and circulation. 
Kraepelin measured the vital signs of thousands of patients with depressive insanity and reported the patterns that he found.  The heightened arousal and distress reported by patients were reflected in the extreme sympathetic activation he found. 
Extreme sympathetic activation will raise heart rate and blood pressure and cause periods of heart arrhythmias, murmurs, and and all kinds of other cardiovascular symptoms;  there are signs of vasoconstriction with cold, pale and sometimes even blue hands, feet and lips. Mild hypothermia [body temperature is lower than normal] or internal/external and hidden bleeding both result in vasoconstriction..
Kraepelin also found abnormal breathing rates [too slow in depression, too fast in mania]. This explains the pattern of the other signs. The feeling of hyperarousal and dread, I suspect came from partial suffocation due to obstruction of the airways by secretions.. Obstruction of the airways can happen to any person with a bad respiratory infection.  I suppose the risk is greater for someone with baseline breathing abnormality.
The most important clue here is the respiratory rate at rest.This is well known but for some reason no one likes it. Measuring respiratory rate at rest is easy, especially with a stop watch. 

Respiratory Rate: The Forgotten Vital Sign-Make It Count!

Loughlin PCSebat FKellett JG.

Jt Comm J Qual Patient Saf. 2018 Aug;44(8):494-499. doi: 10.1016/j.jcjq.2018.04.014. Epub 2018 Jun 20.

Respiratory rate is the sentinel and arguably most important vital sign because its normal values are breached before those of other vital signs in nearly all states of clinical decline. Changes in respiratory rate are often the earliest warning of sepsis, systemic inflammatory response syndrome, shock, and respiratory insufficiency, among others. In these conditions, abnormalities in respiratory rate first herald the need for additional patient assessment and rapid intervention to prevent further decline and unexpected cardiac arrest.

Kraepelin did not think to test the vital signs of his patients when the depressive attack lifted.

We did not think to measure Paula’s vital signs when she lost her mind. 
We did measure Paula’s vital signs when she was slowly recovering. Her breathing rate is very slow with active exhaling. She was not aware that anything was wrong with this until she watched the doctors she told recoil in horror.  When healthy, her blood pressure and other vital signs are normal. 
What was unique to manic depressive attacks was Kraepelin’s finding [and ours] that the breathing rate is chronically abnormal –  too slow or too high throughout depressive and manic attacks.
Because of Paula, we suspect that Kraepelin’s patients had abnormal breathing rates in health. It is possible that these patients have neuromuscular injury of parts of nerves in the chest or neck, making it difficult to raise one’s breathing rate in times of illness with the brain doing its best to compensate.
 It is possible that these patients have permanently broken breathing yet do just fine until their coping mechanisms are overcome due to illness and/or toxicity.

What is also unique is the awareness of physical distress without awareness of breathing difficulty.  This also fits with neuromuscular injury. 
“Severe peripheral nerve injuries may cause total loss of feeling to the area where the nerve is damaged”.Peripheral nerve injuries – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org › symptoms-causes › syc-20355631

Abnormal breathing could definitely explain the distress [dysphoria] and the euphoria and the irritability]. Internal Intoxication or poisoning from changes to the partial pressure of carbon dioxide in the blood could definitely cause these effects. In mania, the pressured speech could be a form of speaking and panting at the same time to increase the amount of carbon dioxide blown off.

The most important clue is the respiratory rate at rest. Neuromuscular injuries can result in baseline abnormalities in breathing rate and depth in health and difficulty under certain circumstances in illnesses.

An abnormal resting breathing rate [along with a possible partial respiratory obstruction from infection] will more than explain the freak out from the rest of the body and the brain [stem] responsible for homeostasis. The chemical imbalance psychiatrists talk about  is most likely to be the abnormal pressure of carbon dioxide or one of the other gaseous transmitters in the blood. Carbon dioxide is the major cerebral vasodilator in the blood. The brain manages breathing rate based on the partial pressure of carbon dioxide in the blood..  Unless of course it can’t. Due to injury.

Reflex reactions to abnormalities occur quickly to help normalize the circulation as much as possible. To Paula, it felt like she had been put on autopilot. She was able to see and hear , she was able to respond to simple commands and she could even drive her car, but intentional and spontaneous speech or actions were very difficult, nearly impossible, in fact, without being able to remember what she was thinking.
In addition, Paula could only speak two or three words before feeling out of breath [which she remembers but did not recognize at the time]. And the words seemed to her more difficult to form [stiffness].As a result, she remained mostly silent. Thinking and talking took more energy than normal. It was just too hard.


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