Paula’s attacks of bipolar depression involves intact recognition of people and places yet with heightened anxiety accompanied by with autobiographic and personal memory loss and dulled intellect. The result is a loss of self despite normal recognition of one’s environment. This loss of self is alarming and confusing and impossible to describe. Loss of intellect makes for poor insight and poor judgement. The experience is unsettling on a personal level. This is what it means to “loose your mind”.
Is the immense anxiety visible to others? Yes and no. Paula becomes visibly quiet and meek and passive unlike her normal self. Only her eyes disclose her terror. And this puzzles rather than informs friends and family.
No one imagines that she suddenly has amnesia for personal details, knowledge and skills. And she cannot report this because she lacks the concept of amnesia due to her loss of intellect and loss of descriptors to describe her memory loss. She recognizes that her mind is impaired and has lost the ability to express herself. She can speak but has nothing to say. Her usual internal and external thinking is gone. Her insight is dulled-impaired. She cannot describe what it is like, what has happened…so she says nothing.
Paula now describes it as being an inept zombie, going through the motions of what one is supposed to do, looking like Paula, almost acting like Paula due to recognition of environmental cues, yet having lost the memory of how to be Paula.
Bipolar attacks are not mood disorders; they are loss of parts of the mind, including loss of baseline intellect and private mind. To have a bipolar attack is to have an attack of insanity [to use Emile Kraepelin’s term – 1926 Manic Depressive Disorder ]. It involves loosing your mind, and it turns out that mind can be rescued….by time, at first….and if that takes too long [as in years, decades], by neuroprotective medications ……. at least in the case of patients with altered ventilation at rest and in response to stimuli such as respiratory or other physical illness.
What is most interesting is that the intellectual mind and memory is suppressed or inhibited in bipolar attacks [both depressive and manic and mixed]. Unlike dementia, which is progressive and slowly leads to death, bipolar attacks can lift spontaneously and the person can regain intellect and mind intact with no damage.
Why? We still don’t know.
If Paula’s attacks of “loss of mind” are linked to the [silent] respiratory depression we have been discussing in this blog [ discovered thanks to Emile Kraepelin’ s astute observations of abnormal control of breathing in this illness], then this is as troubling as the “loss of mind” itself. This is because so far doctors believe that ” There can be no respiratory compensation for a primary respiratory problem.” We think, however, that metabolic compensation and co-ordination of physiologic responses can prevent permanent damage to the mind. …… [ this thought to be continued..]…..This is why Paula and I are able to write this blog about her experience…….The Paxil that she must take is the molecule that restores her ability to think . Paxil is a serotonin agonist and serotonin seems to be important to the maintenance of the liver, the bone, the platelets, breathing, the nervous system, everything in the body really. Perhaps it helps maintain pH or intracranial pressure under conditions of ventilatory stress, such as Paula’s. …..to be continued…..
Acid–Base Physiology I
Joseph Feher, in Quantitative Human Physiology (Second Edition), 2017
Respiratory Acidosis and Respiratory Alkalosis
Hypoventilation in the absence of alkalosis to inhibit ventilatory drive is a primary respiratory problem. This can result from CNS depression caused by trauma [past or present] or by some drugs that inhibit respiratory drive such as barbiturates. Hypoventilation increases PCO2 and leads to acidosis. There can be no respiratory compensation for a primary respiratory problem. In addition, anything that interferes with gas exchange can also cause respiratory acidosis. These conditions include emphysema or asthma. Interference with airflow as in asthma or reduction of the area of exchange as in emphysema can both increase PCO2 and cause respiratory acidosis.
In the absence of acidosis to stimulate ventilatory drive, hyperventilation is a primary respiratory problem. This can result from excess CNS stimulation caused by anxiety or other psychogenic phenomena or by voluntary hyperventilation prior to holding one’s breath under water, for example. Hyperventilation decreases PCO2and leads to alkalosis. There can be no respiratory compensation for a primary respiratory problem. https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/respiratory-compensation
Yet, Kraepelin and Paula observe that this “loss of mind” is completely reversible. This is how I am able to discuss Paula’s experience of madness or inanity or attack of delirium [hypo, hyper and mixed motor subtypes] with her. Paula recovers her wits with time [naturally, in her youth as a young adult] or, as she got older, with serotonin agonists and after her latest attack, the addition of a low dose of lithium. [the lithium needed now to treat the loss of mind and memory in the hypo motor subtype only].
Paula’s breathing rate remains depressed at rest- at baseline- BOTH when well and when having a hypo motor depressive insanity attack [her breathing rate becomes too fast and shallow during a hyper motor attack only- most likely a response to acid base changes ].
This leaves us with the question of what aggravates an already perilous injury like that of Paula’s and possibly other bipolar patients [damage to baseline breathing rate and limitation of physiological response to rising retention of C02] and what chemicals restore pH that allows full function of the brain ie. that of personal function of one’s internal MIND ?
I think that learning more about the link between the lifelong and developmental changes to “control of breathing” [ which after all, involve the function of the brain and the central and peripheral nerves and also the muscles and bones [eg ribs, spinal column, muscles of ventilation]- if not the lungs], will allow us to understand the changes to mobility and to function of our minds as we age.
For example, bipolar attacks begin, it seems, once full height and stable baseline adult ventilation is achieved. Ventilation decreases from birth to adulthood. Baseline ventilation rates per minute at rest during health decrease from birth until young adulthood and no one really understands why.
Although the normal respiratory rate can vary slightly between individuals, there is a range that doctors and nurses consider usual. The following table outlines normal respiratory rates based on age:
|Age||Breaths per minute|
|birth to 1 year old||30–60|
|1–3 years old||24–40|
|3–6 years old||22–34|
|6–12 years old||18–30|
|12–18 years old||12–16|
|over 18 years old||12–20|
The authors of a 2021 articleTrusted Source state that children have a higher respiratory rate than adults. Once a child reaches the age of 2, the respiration rate reduces from 44 breaths per minute to 26.
So what is a normal respiratory rate based on your age ……until you are full grown.
The normal respiratory rate for healthy adults is between 12–20 breaths per minute. At this breathing rate, the carbon dioxide exits the lungs at the same rate that the body produces it. Breathing rates of below 12 or above 20 can mean a disruption in the normal breathing processes. https://www.medicalnewstoday.com/articles/324409
Does the decrease in ventilation upon reaching adulthood explain the development of increased abstract thought which occurs up to age twenty-five ? Paula and I think so. We think that it would be important to understand the link between the development of memory- intellect- abstract thought and the fixed baseline ventilatory patterns of the adult……….
It seems that the pattern of ventilation, of pushing air in and out of our bodies is important work for the stable function of our frontal lobes. Lungs are important. But so is Ventilation. The complex physical act of drawing a breath. And ventilation involves the brain, the muscles, the nerves…the head and neck and abdomen [ and arms and legs during movement]; ventilation involves physical and nervous co-ordination of the whole body.
Paula’s frontal lobe function is labile, her ventilatory rate at rest depressed at 3 breaths per minute. Without the serotonin agonist she experiences inhaling as somewhat difficult, although she thought this normal . It is not normal. Paula uses her tummy muscles to help exhale as fully as she can. This too is not normal. With the help of the serotonin agonist she is able to exhale more completely, the abdominal muscles work better.
These are subtle differences [at least to Paula] but they make a difference. They make a difference to her frontal lobe function.