If the doctor had asked Paula this question, she would have said yes. Paula could still recognize her problem. She could still answer focused questions. Focused questions were really the only questions she could answer.
Paula could not form her thoughts for long and she could not easily verbalize her disappearing thoughts. She knew she wanted to describe her inability to do her job at work. She badly needed help to verbalize this before she forgot. She tried very hard to remember what she had to tell the doctor and she needed the doctor to help her BUT the doctor could not read her mind. The doctor had no idea that this could even happen to a partially functioning person and did not “go there”.
When Paula told the doctor [with a lot of effort] that she was confused, she meant that she had lost her autobiographical memory. She meant that she was neurologically confused. Paula did not know the term “autobiographical memory”. She knew that this could be defined in a neurological way rather than psychological . Autobiographical memory was not even a common term in neurology or psychology then. With scans of the brain and with obvious memory loss in dementia, it has become more of a “thing” in research.
Paula did sometimes manage to say that she no longer knew what to say with people. The loss of memory required to do her job was what upset her most..
If the doctor had helped her to be able to describe what she meant, rather than decide [without much thought] that she could not possibly be delirious or demented or even cognitively impaired, it would have been very helpful.
When Paula expressed concern [despair?] about not knowing how to do her job of 15 years, a job requiring a graduate degree and specialized training; he/she could have helped her to follow this thought by asking her what happens when she tries to do her job?
And the doctor could have helped her to stay on track and not get distracted when giving details of what happens now when she goes to work.
The doctor could have said “Paula, what do you mean when you say you cannot do your job of 15 years?’
Paula would have answered [despite her acute *** Dysphonia] that her “forgetting” started when she woke up feeling a great deal of distress and felt “unlike her normal self”, went to work as usual and discovered at work [when she tried to work] that she’d lost all memory of what to do. [Changes to the voice occur in major depression. ” When someone is depressed, their range of pitch and volume drop, so they tend to speak lower, flatter and softer. Speech also sounds labored, with more pauses, starts and stops. Another key indicator is the tension or relaxation of the vocal cords, which can make speech sound strained or breathy “]. Capturing the Sound of Depression in the Human Voice Dana Smith 2017 https://www.kqed.org/futureofyou/435986/capturing-the-sound-of-depression-in-the-human-voice
See more on dysphonia after the discussion on chronic organ failure].
Now I am sure that if this interaction had occurred between Paula and her doctor, the doctor would have felt panic. Paula looked too well [even though she did not look well at all] to be so seriously ill. The doctor would not have been prepared to hear how serious her problem really was. It was a nightmare and Paula knew that no one would think to examine her medically, or to obtain her vital signs [including her respiratory rate- which was depressed ] and that no one would understand that this was a treatable syndrome.
And yet, there are many syndromes that could cause a chronic course of quiet delirium and cause loss of autobiographical memory with a lot of distress. And these syndromes all involve failure of one or more body system with secondary effects affecting the brain.
The easiest way to figure out where in the body, the failure may be occurring , is to count the respiratory rate to see if it falls in the normal range. Respiratory rate at rest is the most sensitive indicator of impending medical problems. What Is a Normal Respiratory Rate? By Lynne Eldridge, MD March 11, 2021 Medically reviewed by Sanja Jelic, MD https://www.verywellhealth.com/what-is-a-normal-respiratory-rate-2248932
Paula’s respiratory rate, had a doctor counted it at rest, for one minute with a stopwatch, was seriously depressed and abnormal. This strongly suggested that she was experiencing some degree of ventilatory pump failure and needed an emergency medical evaluation.
Since Paula looked relatively well for someone with such a depressed breathing rate , it is likely that she has a chronic problem involving the ventilatory pump system and that she needed help breathing in order to regain her baseline mental and physical condition.
It was a nightmare and Paula knew that no one would think to examine her medically, or to obtain her vital signs [including her respiratory rate- which was depressed ] and that no one would understand that this was a treatable syndrome.
Chronic and progressing organ failure is not well understood , most likely because of all the compensatory systems in the body work together to keep a person alive, even when some parts of the body are failing.
Chronic organ failure of any kind can lead to episodes of chronic delirium [all locomotor subtypes] , which can be reversed with appropriate medical treatment.
Paula knew all this from Dr Emile Kraepelin’s[1926] studies on thousands of patients like her but Paula also knew that no one would think to examine her medically, or to obtain her vital signs [including her respiratory rate- which was depressed ] and that no one would understand that this was a treatable syndrome. Paula was in big trouble.
***Spasmodic Dysphonia Dr. Alexander Hillel, M.D. https://www.hopkinsmedicine.org/health/conditions-and-diseases/spasmodic-dysphonia
- Spasmodic dysphonia is a voice disorder. It causes involuntary spasms in the muscles of the voice box or larynx. This causes the voice to break and have a tight, strained or strangled sound.
Spasmodic dysphonia can cause problems ranging from trouble saying a word or two to being not able to talk at all. [ ***trouble saying much more than a word or two or barely being not able to talk at all can also suggest significant problems with breathing.]
Spasmodic dysphonia is a lifelong condition. It most often affects women, with symptoms starting between the ages of 30 and 50.
There are 3 types of spasmodic dysphonia:
- Adductor spasmodic dysphonia. This is the most common type. It causes sudden involuntary spasms that trigger the vocal cords to stiffen and slam closed. The spasms interfere with vibration of the vocal cords and with making sound. Stress can make spasms worse. Speech sounds are strained and full of effort. Spasms, generally, do not happen when whispering, laughing, singing, speaking at a high pitch or speaking while breathing in.
- Abductor spasmodic dysphonia. This type is less common and causes sudden involuntary spasms that trigger the vocal cords to open. Vibration can’t happen when cords are open so making sound is difficult. Also, the open position lets air escape during speech. Speech sounds are weak, quiet and breathy. Spasms do not happen when laughing or singing.
- Mixed spasmodic dysphonia. This is very rare and is a mix of symptoms of both types of dysphonia.
What causes spasmodic dysphonia?
The exact cause of spasmodic dysphonia is not known. A central nervous system disorder is thought to cause most cases. It may happen along with other movement disorders. Researchers think it may be caused by a problem in the basal ganglia of the brain. This is the area that helps coordinate muscle movement. Spasmodic dysphonia may be inherited. It may start after a cold or the flu, injury to the voice box, a long period of voice use, or stress.
What are the symptoms of spasmodic dysphonia?
Symptoms of spasmodic dysphonia vary depending on whether the spasms cause the vocal cords to close or to open. Speech that is strained or difficult, weak, quiet or breathy may be due to spasmodic dysphonia.
How is spasmodic dysphonia diagnosed?
A speech-language pathologist may test voice production and quality. An otolaryngologist, a health care provider who specializes in the ear, nose and throat, can diagnose the disorder. Along with a complete medical history and physical exam, checking the vocal folds using fiberoptic nasolaryngoscopy may be done. This involves using a lighted tube, passed through the nose into the voice box to check movement of the vocal folds during speech. A neurologist may check for underlying neurological problems.
Of Sound Mind 