When Paula becomes “strange”.

Paula remembers when she woke up “strange”. It was so unlike anything normal. She woke up in terror only to find out later that her memory was impaired. She could still respond normally to objects; she knew that ovens were for baking and roasting, she knew how to work the controls of her car, she could still drive, she recognized people she knew, she could respond to “things”. It was the “personal content” that disappeared.

This is still hard to describe….Paula gave me an example. Having breakfast with her husband was usually a relaxing affair; usually she read the newspaper while he did crosswords. She would comment on what she was reading from time to time, enjoying being together in silence as much as the occasional exchange . . This was a decades long experience for them.

When she became “strange”, Paula seemed to be exactly the same as usual, but she was not. When “strange” Paula had no mental template of “breakfast” anymore. Without a mental “template” Paula was simply going through the motions, but the “content” was gone. It is so hard to describe. . Paula sat, as usual, next to her husband at the breakfast table, in silence. Not a comfortable silence, as usual. She was not herself in that she had no memory of how to be herself in this situation. She sat there and worried. She worried about why she had no idea what to do or say. ; she thought to herself – why the silence? was she supposed to say something? why didn’t she know? her husband looked at ease, how long did they linger like this over breakfast? [she forgot she usually read the newspaper], her mind drew a blank, it was as if she had never had breakfast with her husband before, she had no idea how to behave, when to rise from the table, she tried to act normal, she just no longer knew what normal was…it was so frightening…she worried silently about this yet no one could really tell. Her face gave no hints at her internal fright, her expression was neutral and everything looked normal enough from the outside. Breakfast seemed to last forever and was excruciatingly painful for her, yet she said nothing to her unsuspecting husband….she was too preoccupied by her sudden amnesia to do anything but worry….her thought revolved around her predicament, she seemed to have lost her vocabulary, her ideas, her knowledge, and in addition, what she was going through was impossible to describe. How to describe what you do not understand? Everything she did, everything she encountered, everyone she encountered during the day elicited the same blankness. She worried all day long about what to do, what to say, how to react, in every situation she encountered. Even when alone, all she had left to think about was how this could possibly be. How strange this was. How strange she was. How everyone could see. [everyone could see but they had no clue what it was they were seeing]. How everyone was uncomfortable with her “strangeness”., [and they really were uncomfortable]. How incompetent she suddenly was [she tried to work as usual but lost her know-how. She had to read her lecture word for word because she lost her sense of the content, her sense of comprehension, her loss of timing……she sounded like a seventh grader reading word aloud in a wooden manner. she could’t answer the student’s questions, she simply did not understand the material any more. People laughed in derision. People were angry [her lectures were after all useless now], People avoided her. Paula avoided people. It was so humiliating. A real nightmare. This is the real experience of “loss of one’s mind”, loss of self” , ” loss of memory for self”………..Yet it was subtle in some ways. Colleagues and family were not sure what to make of it and Paula was not “there” to explain it.

What is interesting is how much of our behavior is stereotyped and responsive to the environment. It took weeks for Paula’s friends and family to understand that although she able to go through the motions of getting up, having breakfast, getting dressed, getting showered, driving to work, knowing who everyone was, she was otherwise amnesic for her usual thoughts, her usual reactions, her usual analysis of things, her usual comprehension, and she lived it every moment and was horrified; aghast – every moment…..for over a year.

No one knew. No one could read her mind. She turned inward, wondering what to do-and not knowing, having lost the blueprint, the roadmap of her autobiographical memory.

This was what Paula experienced when she woke up “strange”, strange to herself, having literally lost herself and some of her intelligence and skills. Who could have guessed such a thing was possible?

Luckily Paula is able to recall her amnesia for self now that she has recovered her “self”.

And somehow the only clue to this reversible and specific amnesia for self, seems to be Paula’s abnormal respiratory rate and the possible failure of managing her respiratory gases when in adverse physical health, when her already impaired homeostatic reflexes are overcome.

The effects of hypercapnia [too much endogenous carbon dioxide in the blood] are reversible. Hypercapnia affects mood and affects the mind because it affects the chemical balance of the gases in the blood. The body knows how to handle its own production of carbon dioxide produced by its own cells. The easiest way to manage C02 continuously produced by our cells is to exhale the excess. We do this with our skeletal muscles. Exhaling is a motor act, involving coordination of intact nerves and skeletal muscles and blood and all other organs and tissues reporting to the brain and affecting the brain. Any mechanical difficulty affecting this system makes control of these respiratory gases harder and makes the system less flexible. And respiratory gases can affect the brain and memory and mind.

Paula seems unable to raise her respiratory rate normally, even at rest. Her main response to internal and external stimuli is to increase her depth of breathing. She seems only able to raise her breathing rate if she uses additional skeletal muscles used normally for exercise. Even then, her rate lags and depth increases more.

Interestingly, when Paula was “strange”, despite her ongoing sensation of terror and her frightening experience of loss of her usual self, her respiratory rate still did not rise, as would be normal during strong negative emotion. The rest of her vital signs reacted normally due to sympathetic activation, except respiratory rate, which even declined slightly. Sympathetic activation usually raises the heart rate, the blood pressure and the breathing rate. Sympathetic activation kicks in in response to an external or internal threat; in this case the internal threat seems to be ventilatory failure and inability to compensate for the respiratory acid base disruption in the usual manner [for Paula].

One of Paula’s main systems for adjusting and managing the chemical environment of her blood seems to be broken and yet she is able to compensate with increased reliance of other bodily systems most of the time. This is great news! How does the brain and body do this?

We don’t yet know.

Without doing careful studies on the range of respiratory rates in normal healthy and unhealthy adults, we are not even aware that people have mechanical problems with the motor part of breathing, beyond the lungs.

Yet I cannot help but think that gases around us and inside us are important elements affecting mind, cognition, amnesia , in absence of permeant damage to the brain. And that carbon dioxide produced by our cells is not simply a “waste” gas to be exhaled, but is necessary for normal blood flow to the tissues of the brain and necessary to normal pressure inside and outside of brain tissue and that even mild but continual physical strain on these tissues can affect our experience of ourselves and can affect motor behavior [abnormal responses-too slow or too fast] and also mood [pleasant versus unpleasant ] and even involuntary intoxication-like transient effects such as euphoria or memory loss.

to be continued………

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