Paula had his long period of anguish and partial amnesia when she was unwell ; it lasted over a year. This unbearable sensation of anguish was accompanied by a sudden partial amnesia and mental dullness which she was not always aware of, did not understand and was extremely disturbing. It affected her behavior a lot. She was just not Paula, as she had been before. She looked worried all the time [wouldn’t you?] and hid from people a lot. She did not remember what to do or say around others, even those closest to her. . Paula has never been able to describe this properly till now.
Imagine that the day Paula fell ill, she had her weekly coffee meeting with her close friend Tiffany. Paula wanted to cancel as she felt strange, but she did not know what to say. She did not remember how to tell her close friend that she was not up to their regular meeting. It was weird, because Paula was normally a very good communicator and they could always meet another day. It should have been no big deal, but that day Paula was different. She was not herself. She was suddenly strange. She could not explain it.
Paula went to meet her friend Tiffany for coffee. Usually they would chat about work, boyfriends and family. Her friend greeted her, as usual, and started to relay the events of the week. Tiffany was excited to tell her about a new project at work. Paula just sat there and did not know what to say. Paula’s mind was blank. How could her normally active mind be blank? The encounter was profoundly disturbing for Paula.
Paula did not know what was wrong. She was shocked and distressed [different from and in addition to her sensation of anguish ] by her lack of memory. Her personal memory and reactions was replaced with worry thoughts. What should she say in response to her friend – who was after all, simply telling her about her week. When should Paula say something in return. How did she do this in the past [ie. yesterday]. Paula no longer knew. Paula simply sat there trying to think of what to say and wondering why she had nothing to say and worrying about where her usual thoughts disappeared . The coffee date was less than fun for both of them and Tiffany finally ran out of things to say. Paula felt very uncomfortable and Tiffany looked like she was starting to feel uncomfortable too. Paula felt guilty about ruining their conversation. She knew that she was the problem. She couldn’t seem to be able to do anything about it. She did make some remarks, trying to participate but they sounded wooden, not like her usual self at all. She did not explain anything to Tiffany. She couldn’t. She just wanted to leave.
Paula went home. Her husband greeted her with a hug, as per his usual. Paula did not know how to respond. Did he usually hug her, she thought? Did she usually hug back? What did she usually say after hello? [it turned out that she often asked him how his day went- but she did not remember.] Her husband noticed the difference right away [as had Tiffany] and simply thought that she was in a bad mood or something. But that wasn’t the problem at all. No one could have guessed that she had no memory of her own self and her own behavior. Paula felt like a zombie, just going through the motions and doing a poor job of it. She felt strange and mentally dull. Yet no one could see it; not really. They became uncomfortable with her but were not sure why. She looked normal enough, yet not ?
At the height of this autobiographical amnesia and mental dullness, it turned out that if asked, [and who would think to ask?] Paula could not remember her own address, her own phone number, or even how to do her job of 15+ years-the job she could do so well only yesterday. She did not remember what to do once she got to her work. She recognized everyone. She knew that she should probably call in sick but did not know what to say or how to explain. Without her memory of what to do or what to say or how to converse with people she was strangely and suddenly incompetent. She wanted to hide under a rock. It was so embarrassing to have everything she said and and most of what she did be wrong. [and it was wrong and it was “off”].
Her attention was affected, because [unbeknownst to her] her ability to understand what she heard and read had declined. She no longer fully understood anything. Not even the newspaper she looked at every morning. Not even simple conversations about nothing. She no longer recognized the social cues.
Paula can explain this now that she has recovered. She was unable to explain it then.
This type of amnesia for her usual self lasted over a year, along with the anguish which was separate yet accompanied the amnesia. Her internal arousal levels were high, very high, [hence the anguish and distress] yet her memory of her self was impaired. Arousal and cognition are considered two separate parts of what is defined as consciousness. . Paula was exceptionally alert [as in panicked] and awake, but looked wooden and unfocused. Maybe this explains why she could still drive to work yet forget how she used to be once at work. When she spoke or acted she was painfully aware her own inability to be herself. She was silent most of the time, not because she was depressed, but because without her personal memory of herself and without her normal cognitive abilities, she did not know what to do or say in all situations and she did not know how to tell anyone….It is an impossible thing to explain and she did not have the words to explain it and she understood that no one would know what to do to help her.
For what is mind if it is not first and foremost, memory of one’s self, one’s thoughts, one’s words, one’s actions and of one’s natural abilities. Paula had lost her mind.
Paula spent over a year in this state. She had lots of thoughts during this time. All her thoughts, all the time, revolved on wondering why she could not remember. She could not escape; her lack of memory was present in everything she did. She tried to do her usual chores, say like cooking; but she could not remember how to bake fish, or where the recipe was, or how to look for a recipe, and if she did manage to make fish, she forgot some ingredient and it didn’t taste very good. This was a routine, easy task she never had issues with till now, in this state. She worried all day about her lack of knowledge and about her loss of self.
It was as unbearable as *Kraepelin’s patients described. It was embarrassing. She felt guilty about failing at such routine simple tasks. She could not explain it. Kraepelin’s patients could not explain it either. She could only demonstrate it – through her behavior and by watching how she handled a task [poorly] and on neuropsychological tests.
Simple timed tests showed the the level of memory loss and confusion she was experiencing; she could not remember 7 digits [numbers] forward or backward. She could not retain them in her mind. She could not spell WORLD forward or backward. She could not do serial seven’s, subtract 7 from 100 etc.. because her memory was too impaired. She failed the TRAIL MAKING A and B cognitive tests. And her memory was so impaired that she could not remember her address or her phone number or how to make rice or what to say to her best friend over coffee. Appendix D Neuropsychological Test Descriptions, Cognitive Outcomes After Cardiovascular Procedures in Older Adults: A Systematic Review [Internet]. Fink HA, Hemmy LS, MacDonald R, et al.Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Nov 17.https://www.ncbi.nlm.nih.gov/books/NBK285344/
I learnt that it is extremely important to give a short neuropsychological test to any patient that has behavioural or mood changes resulting in sudden changes in performance, in order to rule out new autobiographical memory loss and new cognitive impairment.
I also learnt [by reading Dr Emile Kraepelin ] that, in the absence of a tumour or permanent brain damage, say from a prolonged high fever or from a severe head injury, this loss of memory and self and behavior may spontaneously lift and normal function may return. [although it could take months, years, or decades during which the patient is helpless to take care of themselves]. I also learnt from Paula’s case, that Paxil could help bring back autobiographical memory and cognition. Paxil could work faster than waiting for spontaneous recovery, even though Paxil had side effects [mania] and still took a long time to work completely. [It took one year for Paula to be able to remember her address, and it took 10 years for her cognitive abilities to become stable and reliable.].
The reversibility of this syndrome strongly suggests that it is a type of long lasting yet curable delirium rather than a dementia [which seems to be permanent and progressive].
The behavior and motor changes are the same as a delirium. Depressive episodes are the hypo motor subtype of delirium and Manic ones are the hyper active motor subtypes and Mixed episodes exist in both syndromes.
Both the insanity of delirium and Manic Depressive Insanity are clinical syndromes and both are often misunderstood , especially the silent hypoactive phase of this disorder.
In both, the patient does not know what is wrong and depends on the caregiver to find out.
In both, the malady will be due to physical causes, which may take some knowledge and imagination to figure out.
And the answer may be in examining and analyzing the rate and rhythm of the motor part of breathing [called ventilation], something which is rarely done today, in non critically ill patients cared for in the I.C U. with fancy machines.
This too, was suggested by Dr Kraepelin toward the end of his career.
Could the essence of “who we are” could be a result of the amount of air we exchange each day? Could the essence of “who we are” be tied to the carbon dioxide our cells produce with the air we breathe?
Breathing too slowly or breathing too fast seems to indicate a problem which may or may not involve the lungs. Moving air in and out of the lungs takes energy . It takes the constant work of the skeletal muscles . Anything that affects these skeletal muscles will affect our ability to move air in and out -even with normal lungs.
While it is hard to understand the gases which flow in and out of our blood and our tissues. It is easy to measure the rate and depth of breathing. The brain controls the rate and depth of breathing in order to maintain the best ratio of gases in the body [gases external to us like air and gases internal to us like the cell production of carbon dioxide] .
It is hard to imagine why the brain would allow breathing that is stable but too slow , or stable and too fast, or breathing that is irregular or with long pauses [apneas]. These patterns of breathing may be obvious under observation [like in sleep apnea] or seamless and natural and invisible without measurement.
Dr Kraepelin measured the respiratory rate and rhythm of patients in the different bipolar states and found that breathing was inadequate in different ways during depressive states and during manic ones. The brain manages ventilatory rate and rhythm in order to keep CO2 levels and pH in check, unless it can’t. And it may not be able to in manic depressive insanity.
Inadequate breathing often suggests problems with the lungs or with the skeletal muscles [and nerves].
And problems with the motor part of breathing can lead to states of confusion, depression, irritability, aggressiveness and [most likely] mania.
Breathing is a complex neurological and motor act which we seem to take for granted. It requires intact communication between the nerves and the muscles which power our ability to move air in and out in the correct proportions. We need oxygen to metabolize what we eat and we need carbon dioxide that is produced by the cells during this process in correct amounts [not too much and not too little].
No one has seriously asked how this process and these gases, both external and internal, as well as production of metabolic water along with carbon dioxide, are involved with mind, the memory of self, and cognition in general.
Paula’s respiratory rate is much too slow at rest. Yet she is able to move air in and out of her normal lungs appropriately, mostly by increasing her depth of breathing. She seems to have difficulty increasing her rate of breathing unless she involves her whole body by standing and moving, [something she cannot do easily if ill and if weak and in poor physical condition. When she is ill [eg. infection] and weak and in poor physical condition], she tends to be sedentary and seems unable to raise her slow respiratory rate enough. When physically ill like this, she is most likely retaining carbon dioxide.
If we measured her breathing rate in health [too slow at rest, yet sufficient to think and remember and act normally] and during and after poor recovery from illness and infection then we may begin to understand the effects of unseen respiratory failure, affecting the balance between oxygen and carbon dioxide in the blood.
All of these behavior and mood changes, in our view, are no different from the mood and motor behavior changes caused by respiratory stimulants and/ or depressants which people ingest or breathe in. Mind, cognition and memory is affected in both. The effects of injury to the respiratory muscles or nerves are long-lasting, more so than voluntarily using drugs or medicines, because without medical intervention, the injury to the respiratory muscles and nerves, will continue to impede recovery from illness, until proper metabolism is restored by supportive medical support.
- Dr Emile Kraepelin, Manic Depressive Insanity Chapter One. 1926.
to be continued…………