Unlooked for because 1] it is very hard to look for a medical problem when the patient cannot give you a presenting physical problem or cannot provide a medical history [not even asking for a medical history is tragic, yet is protocol for psychiatric evaluation]. 2] it is easier to be very simplistic and treat what you see instead of looking further 3] there is no tradition, in medicine or in psychiatry [supposedly a branch of medicine] to look for hidden subtle motor problems affecting breathing [an exquisitely motor function].
All long term mood disorders can be the direct result of being physically ill, and the patient [not being trained to recognize medical illness], will often not display anything else in an obvious way. This is complicated by the issue of an overlap between behaviour that indicates a breathing difficulty and behaviour that indicates a mood disorder. Both will feel make you feel bad. Both will cause you to hunch over in the tripod position in an often unconscious attempt to help to breath. Both will cause you to limit your locomotor activity in order to save energy. BUT only one will cause you to have brain fog…and that is motor impairment of breathing, because only this [and not a mood disorder] will cause you to forget your own address and phone number and give you trouble with your usual level of reading, writing and arithmetic. [these can easily be checked during the medical appointment, especially if it is an hour long psychiatric appointment]. Other forms of unlooked for organ failure will also mess with your mind.
Psychological reflection will not help much, if the brain fog and the mood problems stem from nonspecific organ failure, especially due to nonspecific, unlooked for motor impairment affecting breathing, speech or locomotor activity. Abnormal respiratory motor function will tell you if there is a physical issue involved in the mood disorder.
Separating mood from illness is insane and yet this is what the field of psychiatry is about, this is what they do and this is why this field has not progressed and remains stuck regarding very debilitating illnesses such as attacks of manic depressive insanity.
And all doctors and psychatrists have to do to test this SCIENTIFIC HYPOTHESIS is to check the breathing rate nd heart rate [and signs] and blood pressure and temperature of patients when they first get sick. And this all doctors who recognize mood disorders based on nonspecific behaviour, REFUSE TO DO because of a category error in their thinking. And because they are not scientific and do not understand the notion of hypothesis. And most of all, because psychiatrists and other doctors do not want this hypothesis to be true, because it is scary and brings up the notion of disability [although with supportive care the disability could be treated] and brings up the notion of critical illness and death.
Paula was much closer to having a critical illness than having a psychological illness and the psychiatrists and the other doctors were happy not to know this. They would not want to have to deal with this, they see critical care as something which is not part of their job as psychiatrists or as ordinary doctors. And this is stupid. Every doctor should at least be trained in basic first aid in emergency situations. A baseline breathing rate of 3 breaths per minute and a minute ventilation [RR times Tidal Volume [.5 L,which is normal] means that Paula exchanges 1.5 L of air per minute. Doctors assume [because they never look at RR] that moving speaking people are exchanging 6-8 L per minute. How then, to explain Paula?
And because of improper inadequate training in medicine, leading to simple medical errors in not spotting motor injuries, which will affect vital signs and thus blood pH and PCO2 if not PO2. And pulse oximetry has functional limitations and will not pick up any of these problems and will lull the doctor who depends on this, into a false sense of security, even though they know the limitations of pulse oximetry.
All this because no one wants to count baseline breathing rates of patients.
Because it could be scary. And we cannot explain abnormally low or abnormally high baseline rates and abnormal minute ventilations which no one ever measures. WHAT? WHY? IN THIS DAY AND AGE?
Paula’s baseline breathing rates are very scary. And her lungs are normal and healthy. The problem is motor injuries or control of breathing injuries. And yet she is having coffee and breakfast with me and chatting cheerfully with me right now- albeit on Zoom. She is not sick at all. Yet she is at risk of unseen unlooked for critical illness for which mood disorder should be a clear sign of possible hypercapnic respiratory failure [with normal HCO3 and O2 [pulse oximetry] because of normal lung function.
And points to our complete lack of knowledge about the complex motor act of breathing beyond what we know about the lungs.
And points to our complete lack of knowledge of the complex motor act of breathing, beyond what we know about the lungs, and the function of the brain and of the mind.
If one can accept the fear and go beyond the fear, there is much biology to learn here.