“Our ability to speak is regulated by a number of complex specialized mechanisms [such as the larynx] that coordinate high-level cortical processing, brainstem reflexes, and peripheral nerves…our current understanding of neural control of voice and speech production is based on studies conducted in the past 5 years. ……Speech, the highest level of voice production is under the control of the speech motor cortex—including the laryngeal motor cortex (LMC) and orofacial motor cortex—which coordinate more than 100 muscles used in phonation, swallowing, and breathing (Fig. 1). The LMC is responsible for highly skilled learned laryngeal move- ments, such as speaking and singing”.. 2017 The American Laryngological, Rhinological and Otological Society, Inc. The Laryngoscope Central Voice Production and Pathophysiology of Spasmodic Dysphonia, Niv Mor, MD ; Kristina Simonyan, MD, PhD; Andrew Blitzer, MD, DDS, https://simonyanlab.hms.harvard.edu/files/simonyanlab/files/14155076.pdf
When she was sick, Paula had trouble speaking more than 2 or 3 words. Her voice sounded weak and she had noticed that she’d lost the upper range of her singing voice a few months before. It is likely that Paula also had problems swallowing and didn’t know it. [this is probably part of why she wouldn’t eat or drink]. She did not cough anymore either. The problem could be those 100 muscles or maybe the laryngeal motor cortex or the orofacial motor cortes or those peripheral nerves, who knows?
These are common missed physical signs of breathing problems and dyspnea. Nature and Evaluation of Dyspnea in Speaking and Swallowing Jeannette D. Hoit et al http://sal.arizona.edu/sites/default/files/Hoit%20Lansing%20Dean%20Yarkosky%20Lederle%20%2820%20%20%29_0.pdf
Could certain nervous system reflexes have been injured?, When healthy, Paula reports having the sensation of difficulty inhaling. This is the reason, she feels, that she has to exhale actively…to squeeze as much air out of the lungs in order to make use of the spring-like energy to jump start inhaling.
When healthy, Paula is always singing, and whistling. It seems that the neural reflexes underlying these breathing maneuvers are intact. Paula especially feels the need to whistle when she is walking or moving. It is one of the ways she can change her breathing rate and pattern. She has noticed that whistling [and singing] lead to a sharp intake of breath, helping her to inhale deeply. I imagine that singing and whistling involve muscle work on the part of the face and mouth and tongue, pushing more carbon dioxide out, as well.
There is room for a lot of research here.
Perhaps Paula’s dyspnea [defined as metal anguish by Arthur Guyton Medical Physiologist] was caused by a hidden injury to the vocal cords in the airway. Perhaps Paula had an undiagnosed attack of Vocal cord dysfunction. “ Vocal cord Dysfunction involves inappropriate vocal cord motion that produces partial airway obstruction. Patients may present with respiratory distress that is often mistakenly diagnosed [as asthma]” .https://www.aafp.org/afp/2010/0115/p156.html ,American Family Physician Vocal Cord Dysfunction.
Mania also changes breathing and speech. Mania involves non stop, rapid speech which feels as if the air is and speech are being pushed out involuntarily. Maybe mania releases a lot of CO2; it is kind of like panting with speech.
Paula’s speech during her depressive attack, was further impeded by stiffness in the lower muscles of the face. She had dfficulty physically forming words. It required extra effort. Muscle rigidity happens when a muscle or a group of muscles stays contracted or partly contracted for an extended period. This can be a side effect of medical application of opioids. Opioids in Medicine: A Comprehensive Review on the Mode of Action and the Use of Analgesics in Different Clinical Pain States by Enno Freye and Joseph V. Levy | page 241 May 4 2007
Could endogenous opioid receptors be involved? We know that opioids suppress breathing. Maybe , under certain circumstances [ too slow ineffective breathing] , naturally released internal stores of opioids also cause unpleasant muscle stiffness. We know that the body produces its own opioids. Could Paula’s breathing defect in health and in illness, be caused by naturally occurring opioids in the body?
” Functions of Endogenous Opioids In general, β-endorphin binds to multiple opioid receptors and depending on the receptor, functions to diminish pain, equilibrates food metabolism, mediates cardiovascular regulation, as well as drives euphoric responses attributed to higher order emotional and neurological systems. ” Chapter 8 Endogenous Opioids in the Etiology and Treatment of Multiple Sclerosis, Multiple Sclerosis: Perspectives in Treatment and Pathogenesis [Internet]. Zagon IS, McLaughlin PJ, editors. Brisbane (AU): Codon Publications; 2017 Nov 27.
When healthy, Paula is always happy, always content, it is frankly a little annoying for the rest of us mere [grumpy] mortals. Could she be naturally a little high due to naturally occurring opioid release to offset the pain [that is noticeably absent] of working so hard to push out all that carbon dioxide from her body with only 5 deep breathes, something which should be impossible to keep up all day?