Most patients who are admitted to the hospital with the symptom of mental status alteration actually have encephalopathy as the cause. By Richard D. Pinson, FACP https://acphospitalist.org/archives/2010/09/coding.htm

Measuring respiratory rate at rest is one way to clinically diagnose an encephalopathy caused by a defect or injury to the anatomical parts of the respiratory muscle pump so necessary to metabolic function. The parts of this pump change as the individual grows from birth till adult skeletal height. I imagine that anatomical differences affecting bones, nerve fibres and muscle can explain JS Haldane’s findings that the range of respiratory rates in healthy adults is very wide, from as low as 3 breaths per minute at rest to as high as 30 breaths per minute at rest………in healthy adults.

Doctors tend to overlook anatomical differences affecting the chest and neck and limiting respiratory rate at rest. It can make a difference if one gets sick. People with respiratory rates at both extremes must be at risk for respiratory failure type 2 [hypercapnia] and do not know it. No one is aware of their respiratory rate at rest; it is seemlessly coordinated by the brain stem and the respiratory muscle pump. So it is rarely diagnosed in people who appear to have intact anatomy, even after physical trauma. So what looks like depression, mania, psychosis….may be this neglected form of encephalopathy.

“The difference between the almost right word and the right word is really a large matter. ’tis the difference between the lightning bug and the lightning.”

― Mark Twain, The Wit and Wisdom of Mark Twain

And if you lose your mind like Paula did, it is the difference between working to unmask and treat the encephalopathy or to abandon her to her new awful reality of benign well meaning but wrong headed neglect. Mark Twain got it right; words do matter, especially in medicine.

Why wouldn’t doctors like psychiatrists start to measure breathing rate and even learn to test minute volume to identify respiratory pump defects that might lead to the mood and behavioural patterns they are used to seeing? Why don’t they want to learn about acid base problems in their patients? Especially when these problems occur frequently and almost always lead to patterns of “stereotyped psychiatric” mood and stereotyped “psychiatric behavioural disturbances.

Why are doctors and psychiatrists more curious about the human condition? Why would they not entertain new ideas?

Why didn’t Kraepelin succeed in convincing his peers that metabolic dysfunction could cause a stereotyped delirium?

Kraepelin was a better researcher and more meticulous about learning about the vital signs of his patients. Kraepelin helped us learn what was wrong with Paula. All his observations turned out to be significant for Paula.

That is encouraging news. Learning more about a syndrome is a good thing.

Why are psychiatrists not more interested?