I am finding that physical conditions may cause psychiatric conditions.
We are all stuck in our ways of thinking and we do not even look to see if the vital signs of these symptomatic psychiatric adults are normal or not.
I have thought about this a lot since finding out about my friend and colleague Paula. For those who are new to this blog, Paula has one major hidden abnormal vital sign that we found out by accident at a basic first aid class. She didn’t realize this herself. Vital signs are coordinated by the autonomic nervous system and are unconscious. Even one’s respiratory rate at rest is largely unconscious. Vital signs signal whether basic physiology is normal or not in otherwise healthy people and will predict problems, physical and behavioral problems whenever physical conditions challenge one’s physiology further than normal.
In particular, respiratory challenges are a common part of being alive; allergies, upper airway inflammation, exposure to noxious gases…..all are common challenges. And some of us have more difficulty managing these challenges than others.
What do I mean?
We found out that Paula has a respiratory rate of 3 breaths per minute at rest. We eventually learnt that she uses active exhaling to squeeze as much air as she can out of her lungs, in order to increase her tidal volume. In this way her minute ventilation [the amount of air she exchanges with each breath] is adequate. But this takes effort on her part. She is unaware that this is abnormal, she thought everyone did the same [they don’t]. In health ,her lungs and her lung function are normal.
Scientists of the last century [Severinghous, JS Haldane ] knew from their own studies that the range of respiratory rate at rest in healthy adults was very wide- from as low as 3 breaths per minute to as high as 30. But, you can guess that flexibility is curtailed at either extremes.
Paula cannot raise her breathing as is normal when encountering challenges. Her breathing rises sluggishly when exercising and again the brain coordinates tidal volume to exchange enough air. If enough respiratory challenges are present she is at risk of an attack of hypercapnic acidosis, due to ventilatory failure.
Strangely, this happened to her only once, during a period of hormonal change [menopause] which must have pushed her system over the edge. It lasted for over a year. No one examined her. No one evaluated her vital signs. No one counted her respiratory rate at rest [doctors do not do this ever].
We discuss this in our blog where we learnt a lot about the motor act of breathing and its relevance to the acid base of the blood. We have had help from a friend, a lung doctor/physiology professor.
Most doctors do not know about the wide range of breathing rates. Most doctors are not interested in “Control of Breathing” issues. Paula’s doctors had never heard of anyone with such a low breathing rate and they were very worried, even though Paula was completely healthy when they saw her. Doctors do not know anything about they do not think to measure.
Except for one insightful doctor/researcher, again from the last century. Dr Emile Kraepelin thought to measure the vital signs of his manic depressive patients. He found that in the depressed insanity stage his patient’s respiration was depressed at rest [like Paula’s]. When they had psychomotor retardation, their other vital signs responded in a set pattern, blood pressure and heart rate were raised [sympathetic activation] and body temperature declined with peripheral vasoconstriction. [cool and pale hands, feet and lips]..This happened to Paula as well when she showed signs of psychomotor retardation.
Psychomotor excitement and mania came with its own pattern of abnormal vital signs; irregular, fast respiratory rate, lowered blood pressure and intermittent bradycardia with raised body temperature.
But why does this happen? Kraepelin thought that these patients had respiratory defects or nonprogressive injury. It is not hard to see why, once you measure respiratory rate again and again in unmedicated symptomatic patients.
In Paula’s case, we found out that she had a difficult birth and was suctioned [swallowed meconium], resuscitated and transfused; then she appeared completely and absolutely normal [or so we thought]. .No one knew that she had suffered a non progressive ventilatory injury because that is how smooth the nervous system is in doing a “work around” that manages anyway. Paula has looked and acted normal in every way, through childhood diseases, [measles, whooping cough, etcc..] and adult viruses and colds and stomach flu, etc] . Until a situation is encountered where the system becomes overwhelmed and needs a little help [supportive medical care for hypercapnic acidosis]. Is that so much to ask?
But her unusual birth explains her “relatively stuck” ventilatory rate It explains how the rest of the body has to adjust in order to maintain her minute ventilation and the normal pH of her blood. It explains how extra medical support can help during a crisis, as it helped long ago during her birth.
What looked like a depressive attack was an unknown attack of ventilatory failure ,in our opinion] hence the behavioral consequences. She did not know what was wrong with her so she could not say. She felt awful because dyspnea can feel like anguish and distress which feels like it comes out of nowhere. Hidden ventilatory failure can have a remitting and relapsing course and it can cause mental confusion. She moved as little as possible because she was conserving energy. Getting barely enough air is scary and is an unpleasant experience, especially when you do not even know that that is the case.
We discuss in our blog how we got Paula back, by evaluating each medication she tried.
Paula is OK now. No one will misdiagnose her again should she ever get sick again. Because I know what is wrong. [if she gets sick again, she will be as incapacitated as she was then]. I will speak up on her behalf.
But what of others?
Doctors resuscitate babies, children and adults all the time now. How many have ventilatory non progressive injuries [ RR too slow, RR too fast…at rest] and have physical and behavioral problems during basic illnesses and conditions causing breathing to be more difficult. How many will have other injuries affecting basic vital signs they know nothing of. It is time we investigated these as the cause of the behavioral disturbances we see.
The vital signs work to maintain acid base balance and thermoregulation. If vital signs are abnormal, then behavior can be co-opted to help maintain balance and body temperature. And acid base problems do not necessarily show up in blood tests when lungs are fine.
We neglect motor injuries affecting the motor act of breathing, yet the motor behavior of moving air in and out of the body is what is used to manage respiratory acids.
These are not trivial issues. And yet we ignore RR simply because we assume it to be normal , reacting normally during ordinary life challenges. [You know what they say about assuming….]
It is time we examined the function of the motor part of breathing in unmedicated healthy and sick adults in order to learn more about involuntary unconscious reflexes we all rely on to be alive and well.
We think that this is fascinating stuff.
We hope you do too.
Please share these ideas with others.