The underlying cause of bipolar depressive attacks

is inflexible and insufficient breathing rate at rest when challenged by the biological stress of physical illness . Breathing rate that remains ” stuck” at rest during illness will not be able to manage the acid base fluctuations of biological stressors such as infection, blood loss, injury and surgical operations. Additional medical and nutritional support will be necessary to properly heal from physical nonspecific illness. .

Without medical care, the result will be a chronic pattern of delirium- all motor subtypes including mania. It seems that in health Paula’s body and brain have adapted to her very slow and deep effortful breathing at rest in ways that we do not completely understand. After all, she takes in less air per minute than most everyone else, when she is well. Her minute ventilation when healthy is 1950ml or 1.95 litres per minute instead of the normal 5-6 litres. No one knew this. No one measured her minute ventilation, which consists of tidal volume [obtained from spirometry] times breathing frequency. Her tidal volume is 650 ml and her breathing frequency is 3 breaths per minute which equals only 1.95 litres. This fact alone suggests that we need to do more research and we need to understand the range of minute ventilation in health.

The underlying reason for her yearlong attack of quiet, internal arousal,distress, agitation and anguish [pure fear] we believe , was her inability to raise her breathing rate accordingly in the face of biological stressors that should stimulate breathing rate and depth at rest. Biological stressors like infection, inflammation, partial obstruction of the airway, etc… Biological stressors that do stimulate the sympathetic nervous system, EXCEPT for breathing rate in Paula. The rest of the system reacts normally to the biologic stressor- her blood pressure and heart rate rise but her breathing rate doesn’t……..It .remains low, even a touch lower than her baseline at rest.And it is very low at rest always. This is the underlying problem with Paula.

This was also the underlying problem with Kraepelin’s depressive bipolar patients. This is why he KNEW they were having metabolic issues. This is why feeding, sleep, locomotor and activity are affected. Arousal in the form of unbearable and indescribable distress is very very high in bipolar depressive insanity…we think that this is the normal physiological reaction to a gradual non progressing mild hypercapnic respiratory failure with normal lungs and heart and kidneys and other systems of the body.

The respiratory response to biological stress is automatic, unconscious. It is determined by the brain stem, unless the respiratory muscle pump system is stuck…broken.

We are convinced that this is what Kraepelin observed in his thousands of depressive insane patients in the 1900’s. He said it! He discusses the physical signs of bipolar attacks in Chapter 3 of Manic Depressive Insanity. We recognized what he was talking about in Paula. The physical signs are nonspecific yet very specific. They show an abnormal pattern of vital signs. The vital signs are abnormal during all phases of attacks, depressive, mixed and manic.

We knew what to measure in Paula because we copied Kraepelin’s example and measured her breathing rate during her attack. It is basic first aid, you do not need to be a doctor to measure respiratory rate at rest for one minute [using a stop watch], blood pressure, heart rate and body temperature. Careful measurement of vital signs is the best way to identify serious physical illness and delirium [or reversible dementia].

We did not understand what we were seeing because we knew nothing back then, of respiratory physiology. Doctors and physiologists we talked to refused to believe us and refused to measure her breathing rate or her body temperature [which was lower than normal]. They refused to explain why what we told them was so troubling to them. What it meant was that their knowledge of respiratory physiology was incomplete.

The reason for the mania part of manic depressive insanity also seems to be linked to the inability to manage respiratory acid base challenges at rest. Thus motor activity and behaviour is activated by the brain in order to 1] warm up the body and 2] speed up the rate of breathing by activating mechanisms involving exercise [those motor reactions are more normal-more or less.- OK they are not totally normal, hence the mania the the too fast and chaotic breathing observed by Kraepelin during this locomotor stage of delirium..

We know from Paula that her breathing rate increases with exercise and the speed of movement helps increase the speed of breathing…but not enough. When Paula runs up the stairs fast, she becomes breathless as is normal, and her breathing rate rises- but not even to 12 breaths per minute. Perhaps speaking very fast and very loud and responding to stimuli too fast and dancing [like a maniac] helps to increase breathing further-as would be necessary to counter the continuing biologic stressor.

In mania, the brain stem can organize the system and pull out all stops [eg. increase the action of the thyroid, maybe increase levels of testosterone, insulin, etc… ] in order to speed up breathing rate by means other than only the broken, stuck skeletal respiratory muscle motor system. The brain can control the entire body, including glands and behaviour-if it needs to- in order to contain pH and preserving life in the face of unseen and unfelt mechanical problems with the respiratory pump.

Locomotor-respiratory coupling (LRC) refers to phase locking of running and breathing so that the same number of steps occur during each breath, and has been observed in numerous vertebrates, including birds, dogs, hares, horses, wallabies and humans [2][3][11][12][13]. LRC is a form of entrainment, in which the two rhythmic activities with different frequencies become phase-locked due to mechanical and neural interactions. LRC has been suggested to have a number of important physiological effects. These include reducing the energy cost of breathing [14][15][16][17], minimizing conflict in muscles that contribute to both functions [6][9], body stabilization during motion [11][18], and enabling trunk bending and inertial movements of soft-tissues to augment pumping of air in and out of the lungs [2][19]. PLoS One. 2013; 8(8): e70752. Published online 2013 Aug 12. doi: 10.1371/journal.pone.0070752 Impact Loading and Locomotor-Respiratory Coordination Significantly Influence Breathing Dynamics in Running Humans Monica A. Daley, 1 , * Dennis M. Bramble, 2 and  David R. Carrier 2

Perhaps locomotor-respiratory coupling is altered in people with broken respiratory skeletal muscle pumps. This requires further research.

Neither Paula or Kraepelin’s patients complain of breathing problems although we see the effects -euphoria, intoxicated like states, competitiveness, aggressively, anguish, fear, inability to think straight, problems with working memory, periods of dulled intellect, dysphoria…all consistent with mild non progressing hypercapnia respiratory failure in a otherwise healthy adult.

We think that relapsing remitting attacks of manic depressive insanity are attacks of a specific type of delirium resulting from a non progressing mild respiratory pump muscle system failure. We think that this is what Kraepelin was trying to explain, over a century ago.

We need to learn more about the damage that limits the ability of the respiratory pump to work properly and the concessions the body makes to keep that person alive in health and during respiratory challenges of illness.



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