And Paula’s motor control of breathing issues illustrate this.
Paula remembers well what being sick was like. She woke up one morning, after recovering from a number of short lived illnesses feeling incredible anguish . This anguish was unlike anything she had ever experienced. It was a physical sensation , not a feeling. Paula immediately understood that something was physically very wrong with her.
Paula was not aware of the other signs that accompanied this state. She was not aware yet that speech was physically difficult for her and she could not say more than a few words before running out of breath. She did not yet know that she could still think, but could not remember what she was thinking, before [not] acting on her forgotten thought.
She did not realize that she no longer felt sensations like hunger, thirst or the need to relieve herself. She did not know that she was in a state of “altered mental status” when she woke up feeling strange that fateful day. Thus she could not explain what she did not know.
Yet she somehow understood that she was seriously ill and would likely be misdiagnosed. She suspected that she would receive a psychiatric assessment instead of a medical one. She thought she was never going to get well as a result of this mistake. She figured that no one would investigate what was wrong with her.
Psychomotor retardation, psychomotor excitement, altered mental status, stable baseline changes in ventilatory rate and depth at rest, changes in blood pressure and heart rate and body temperature; these are effects of external and internal neurotoxins as well as illness and injury. These are the effects of the different stages of bipolar depressive and manic insanity. This is no coincidence. This reflects disturbances in metabolism, most likely acid base metabolism. This was what Dr Emile Kraepelin suspected was causing the behavioural changes of bipolar attacks.
Poisons, drugs and intoxicants [and medicines such as anaesthesia, benzodiazepines, and psychiatric tranquilizers such as antipsychotics] are chemicals and also will produce dose related neurotoxic changes.
Paula wasn’t taking any pills or intoxicants. So why did she suddenly exhibit such involuntary clearly neurotoxic changes?
Barring exposure to environmental toxins like lead, mercury, arsenic, carbon monoxide, even carbon dioxide [from indoor heating fuels or poorly ventilated overcrowded workplaces], what could cause Paula to have such an attack?
I think that Paula and I have an answer, thanks to luck [the first aid class we took together], and thanks to Kraepelin’s extensive research on manic depressive insanity and thanks to our repeated measurement of Paula’s ventilation rate, [the motor part of breathing].
The rate and depth of one’s breathing at rest is involuntary and, if abnormal at rest, is an important sign of neural and motor damage limiting the body’s response to increased endogenous carbon dioxide in the blood and tissues [endogenous carbon dioxide being a normal product of aerobic metabolism] .
Endogenous carbon dioxide is a product of cell metabolism and must be exhaled in correct amounts.
Respiratory Pump failure can occur due to fatigue from infection or from injury and blood loss and failure of other organ systems [eg. heart failure or kidney failure]. Respiratory pump failure will change the ratio of 02 tp C02 and change cerebral perfusion and intracranial pressure, thus affecting physically affecting the brain, behavior, mood and hormonal release. Respiratory pump failure is subtle, easily missed, and results in a terrifying sensation of anguish from internal factors affecting the blood and tissues.
Ruling out difficult to see or diagnose motor respiratory pump failure requires knowledge of respiratory rate at rest. If at the extreme of normal in health or illness, then mood [anguish, fear, depression] and behavior [psychomotor retardation] and mental status [impaired, diminished ] will suggest the need for medical support to help fight possible infection, internal bleeding, muscle wasting and weakness, fatigue affecting the ability to move air in and out of the lung. Until the person recovers their normal mental state, mood and behavior.
Counting Paula’s ventilation rate showed evidence of damage to her central nervous system; at rest, in health, Paula not only used forced exhaling [not normal] but also had very depressed respiration rates at rest [3-5 breaths per minute]. She was at risk of respiratory pump failure and failure to manage respiratory acids during a respiratory crisis. No one knew. She did not know. This was the cause of her attack of bipolar depression.
Further testing from a pulmonary lab showed that Paula had increased depth of breathing at rest during health , made possible by forced inhaling and exhaling, which takes a lot of effort. Paula was completely unaware of this. She felt her breathing to be normal. [it is not] . This involuntary tactic resulted in just enough air being moved in and out of her [normal] lungs.
Paula is at risk of pump failure [her lungs are healthy], during the added stress of physical illness, infection, blood loss, injury, etc.. and / or exposure to asphyxiants. The added mechanical stress to maintaining the motor act of breathing, [ given the damage already present ] , would definitely cause some level of alveolar hypoventilation and carbon dioxide retention. The evidence of this are mostly behavioural [changes to locomotor activity and speed] and involve mood changes [anguish/ euphoria/irritability] and altered mental status.
Abnormal breathing rate and depth would cause neurotoxic effects on the brain, since increased carbon dioxide in the blood would increase cerebral vasodilation and would increase pressure in the head and press on tissues causing stereotypic changes to behaviour and sensation and mental status [nhibited/excited]. The same dose related stereotypic inhibited/excited locomotor changes are seen in animals exposed to external neurotoxins or poisons when these neurotoxins affect the brain and the body and the blood. And of course, the motor part of breathing will most certainly be inadequate in meeting the challenge of rising exogenous carbon dioxide levels in internal tissues and resulting in cerebral vasodilation and increase pressure in the head and pressing on vulnerable soft brain tissues.
Exogenous [internal] toxins exist. The brain is very practiced in dealing with fluctuations of chemicals produced by cellular metabolism. C02 in excess is one such molecule, ammonia is another, and I am sure there are many other dose related endogenous chemical s which can cause signs of intoxication [mania] or mild suffocation [anguish] when mechanical body parts [internal or external] break down.
Motor [physical, neural, mechanical] control over ventilation and respiratory muscles are key; infection, blood loss, exposure, under-nutrition can cause weakness and wreck havoc with the strength of the respiratory muscles and thus make it difficult for the body to maintain the normal ratio of air needed for normal homeostasis, acid base control, mood and behavior.
Paula and I think that increased risk of respiratory pump failure due to central nervous system defects, under conditions of infection or blood loss, is the cause of the neurotoxic effects of bipolar depression and mania.
Kraepelin found evidence of abnormal ventilatory rates in thousands of bipolar depressed and manic patients, from depressed ventilation to irregular ventilation.
Paula found out in a first aid class that she had abnormal ventilation at rest in health [depressed ventilation] putting her at risk of respiratory pump failure, during periods of infection, blood loss or exposure.
Respiratory pump failure with normal lungs will cause neurotoxic effects affecting locomotor activity and speed plus altered mental status because of the disturbance of ratio of gases in the blood and tissues.
Respiratory pump failure is under diagnosed because shortness of breath is not visible and because lung function is often normal and because the patient is unaware of the C02/pH imbalance causing their symptoms.
Careful measurement of vital signs at rest , including respiratory rate, is the only was to identify this syndrome and doctors do not measure the ventilatory rate and so often miss this diagnosis and confuse it with a psychiatric one.
Respiratory pump failure causing neurotoxic , dose related effects may be the cause of delirium [different locomotor types] and needs to be studied more carefully .
Measurement of respiratory rate to look for abnormalities is important as a first step. If abnormal, tidal volume , minute ventilation and arterial blood gas measurements will teach us a lot about the many neurotoxic effects of respiratory pump failure and stereotyped altered mental and locomotor status.