I am not referring to what we choose to think or what we choose to do. I am talking about the processes which support the existence of Mind ; the chemical processes which are responsible for thought, memory and arousal. These chemical processes depend on energy, on electrical signalling, on appropriate intracranial pressure, on appropriate acid base balance, on appropriate brain temperature, on fuel [eg.glucose], and on adequate circulation of blood containing adequate ratio’s of oxygen/carbon dioxide plus other required substrates.
The autonomic nervous system tries to manage the correct conditions necessary for all organs to function at their best, including the brain and the mind.
These “good enough” conditions involve generating basic levels of body heat, exchanging normal amounts of air, limiting retention of carbon dioxide and maintaining normal levels of acids and bases in the blood. These factors also affect intracranial pressure and blood pressure.
The depressed mood, decreased cognition, the decrease in appetite and feeding, decrease in body heat, decrease in motor activity, decrease in cognitive activity, increase in cortisol [see Qin, Dd., Rizak, J., Feng, Xl. et al. Prolonged secretion of cortisol as a possible mechanism underlying stress and depressive behaviour. Sci Rep 6, 30187 (2016). https://doi.org/10.1038/srep30187] , the decrease in sodium pump activity [corrected by lithium — Huang X, Lei Z, El-Mallakh RS. Lithium normalizes elevated intracellular sodium. Bipolar Disord. 2007 May;9(3):298-300. doi: 10.1111/j.1399-5618.2007.00429.x. PMID: 17430305.], can all be reactions to internal stressors instead of external ones. Stressors such as hidden infection, hypoxemia, hypercapnia, acid base problems or effects loss of substrates like vitamins].
For example, the depressive/anxious mood and defeating thoughts may be the result of the very real cognitive impairment of bipolar depression- even if one cannot explain that one is cognitively impaired, the decreased appetite and feeding might be due to infection or inflammation during or after a virus, the increase in cortisol could ultimately be an attempt to reduce inflammation, especially if inflammation was making it difficult to breathe or talk or is affecting some other basic function, a decrease in ion pump activity would definitely stimulate the HPA Axis because a decrease in ion pump activity is bad and would definitely stimulate the amygdala to respond with fear and dread, etc….
In the search for possible internal stressors causing reversible attacks of bipolar illness, we should start by searching for known causes of reversible brain dysfunction or altered mental status.
And we should start by evaluating respiratory rate, heart rate, heart signs, blood pressure and body temperature to get a broad idea of the state of the body.
Blood gases and sleep studies with capnography will help to see whether periods of hypoxia and/or hypercapnia and/or acid base imbalance are responsible for the altered mental status. Hypercapnia can also raise intracranial pressure and affect brain function.
Blood tests investigating B12, B1, B3, iron, ferric iron, malnourishment, etc… to see if these substrates are sufficient would be useful since lack of these vitamins can cause altered mental status.
Patients should be carefully investigated for hidden infection [ CNS infections such as meningitis. Encephalitis. Septicemia. Pneumonia. Urinary tract infections].
Why is it that no physical investigations are done for bipolar illness, not even basic vital signs are evaluated, why is this ?
Even when a patient is sick enough to be hospitalized, no physical investigations are done in hospital. What a missed opportunity – don’t you think?
Internal sources of stress are ignored; heart issues, abnormal vital signs, measurement of cognitive impairment, etc….it is as if psychiatry is ignorant of all the possible causes of altered mental status.
Chronic impairment of mood and cognition is somehow linked to the physical findings of Kraepelin [see the post before this one] and our findings regarding Paula and her abnormal vital signs.
Clinical psychiatry still assumes that depressive illness results from environmental (stress). This despite evidence of inflammation [Lee CH, Giuliani F. The Role of Inflammation in Depression and Fatigue. Front Immunol. 2019;10:1696. Published 2019 Jul 19. doi:10.3389/fimmu.2019.01696, and evidence of structural changes to the brain – eg hippocampal volume, changes to prefrontal cortex, etc….[Zhang FF, Peng W, Sweeney JA, Jia ZY, Gong QY. Brain structure alterations in depression: Psychoradiological evidence. CNS Neurosci Ther. 2018;24(11):994-1003. doi:10.1111/cns.12835] .].
Paula’s experience tells us that the environmental stress rises exponentially when she becomes cognitively impaired and begins to fail at the tasks she is responsible for. So what looks like a stressful situation IS a more stressful situation BECAUSE the person is suddenly incapable of performing as usual and is only partially aware of it and feels horrible when suddenly incapacitated and incompetent.
When this happened to Paula, she also felt terribly guilty because she knew she was doing a bad job and she knew she had been capable of doing a good job before her sudden attack of cognitive impairment due to depression. And due to her altered mental status she was unable to explain her sudden disability, her words went missing along with her baseline abilities. So environmental stress UNMASKS the altered mental status and anxiety/despair that accompanies the cognitive impairment.
We assumed that tissue hypoxemia and/ or hypercapnia and or problems with intracranial pressure and/ or cerebral blood flow and or heart issues interfering with circulation of blood to the brain and/ or an acid base issue were at play because of her depressed breathing rate and potentially inadequate flow of air in and out of her [intact] lungs. Unfortunately, no one examined her for any of these things while she was incapacitated and ill.
Clinical psychiatry has to become knowledgeable in the chemical processes underlying life, organ function and mind. This means learning to investigate acid base levels, circulatory issues, malnutrition and loss of weight, possible internal bleeding and inflammation and hypoxemia/hypercapnia which might be responsible for manic depressive insanity.