The brain somehow preserves our sense of self….but not when we exhibit altered mental status. Then the brain will direct its energy away from our sense of self, in order to stay alive; whether we have depression, mania, hypertension, ventilatory failure, chronic obstruction pulmonary disorder [not necessarily the same as ventilatory failure], heart failure, kidney failure or malnutrition [from loss of appetite when ill with a virus or when poverty created food insecurity [or partial states of starvation]. Altered mental status is debilitating.
Altered mental status is easy to see but hard to name. We tend to use other terms – non medical ordinary terms- to describe the patterns of altered mental status we see in others – terms like depressed, agitated, irritable, manic, sad, lethargic, passive, strange, euphoric, lazy, incompetent, …and on and on…..and we avoid terms such as altered mental status, delirium, dementia [perhaps reversible if only we can figure out what’s wrong] because these terms mean that something is dangerously wrong……..still working on writing this……..
How Our Brain Preserves Our Sense of Self ; One brain region is crucial for our ability to form and maintain a consistent identity both now and when thinking about the future By Robert Martone in Scientific American https://www.scientificamerican.com/article/how-our-brain-preserves-our-sense-of-self/
This paper is important because what Paula experienced during her bipolar depression was loss of her sense of self ! This is what we have found so so difficult to express and to communicate to others.
Paula and I are of the opinion that loss of the self is the central feature of serious mental illness such as bipolar illness, NOT mood disorder. Her mood was very appropriate for someone with altered mental status, thank you very much!!!
Sudden loss of memory for self accompanied by sudden sensations of free floating distress and fear is a pattern of altered mental status and altered arousal. In this pattern arousal is very high [high blood pressure and heart rate] and content is impaired [dulled intellect and memory for self]. Loss of self is the reason for the incapacity of serious mental illness and it is the reason for the stigma attached to serious mental illness. Loss of self is visible to others on a gut level, if you will, but not on a cognitive level. People react to a person’s loss of self with fear and discomfort. This fear and discomfort seems to be instinctual and universal.
Loss of self will change the personality and make a person more unpredictable in their reactions to others. Loss of self causes an immediate loss of insight and loss of the ability to tell someone else what is happening. This why serious and incapacitating mental illness is so mysterious.
Paula says that what is so strange about loosing one’s sense of self is that you do not know what it is that you have lost. It is “as if” the concept of “self” is an abstract one that you can no longer access. This is an exceptionally distressing experience and one that is impossible to describe when it is happening……because of the suddenly altered mental status.
We think that there is nothing wrong with the brain in Paula’s case but there is a big problem with her ability to breathe and exchange enough air, normally and especially after some physical insult such as infection, and this impaired ventilation causes chronic periods of reversible altered mental status.
As such, we think that Paula suffered a period of the slow motor kind of delirium [hypo-active] or depressive delirium and because the medical and psychiatric community are unaware of the completes of compensated chronic ventilatory issues or if acute on chronic ventilatory failure they miss opportunities to correctly figure out how to help the patient [in this case Paula] regain normal mental status.
Paula, it seems, will never regain normal ventilation or control of breathing [her respiratory rate is 3 normal breaths per minute] with or without intact mental status but this does not really matter since Paula has had normal mental function all her life with the exception of a few attacks of acute on chronic ventilatory failure [we are hypothesizing] which either lifted spontaneously [in her early twenties] or lifted with the help of a serotonin agonist which she will need to take her entire life.
After a mild bout with Covid, Paula had another attack of altered mental status while taking Paxil [first time 15 years] and had to increase the dose and add a small amount of lithium [ neuro-protective –see past blog posts for the research findings] to restore her baseline normal mental status once more. She is continuing to stay at this increased dose.
It would be nice for someone to study how Paxil helps in cases of ventilatory failure.
Paula and I have visited friends on psychiatry wards who were not as lucky to figure out why they are suffering from attacks of altered mental status [remember, the cause is always physical and can involve any broken parts of the body so it can be very hard and take a lot of physical investigating to figure out how to bring the person back from a chronic delirium] . These friends were made to linger aimlessly in the psychiatric wards, they were made to attend art class [a version of basket weaving] and group therapy to discuss social situations and feelings; all of which is a rather tragic way to deal with what [for a subset of them] is a chronic attack of delirium.
Our friends stayed weeks without anyone checking their respiratory rate or their tidal volume or their minute ventilation or an exercise test or kidney function or checking for effects of malnutrition from lack of appetite [in bipolar depression] or for sleep apnea or central hypoventilation and on and on and on and on…………..
Because of ignorance and discomfort with chronic states of delirium, hypo motor, hyper motor [manic being one pattern] or mixed on the part of all humans, whether doctors or psychiatrists.
Serious mental illness is nothing more or less than altered mental status.
Sudden onset of serious mental illness in adulthood, causing motor changes, personality changes and cognitive impairment is an attack of altered mental status, which stems from some unknown, difficult to discern physical dysfunction. Physical dysfunction involving any organ in the body, including the heart, the kidney, the liver, the blood, the head, the neck, the spine, the autonomic nervous system etc….the list is endless.
The first step towards finding a cause is to carefully measure the breathing rate at rest for 5-10 minutes [with a respiratory plethysmograph? mechanical or electronic or even manually] and the rest of the vital signs.
An abnormal respiratory rate pattern and rising C02 in the blood will send a “suffocation” signal to the sympathetic nervous system and will result in raised blood pressure, faster heart rate, and vasoconstriction of the extremities and possible changes in body temperature. The respiratory rate should rise as well, with activation of the sympathetic nervous system. Respiratory rate that is depressed and that does not rise with the Fear signal or the normal activation of the sympathetic nervous system [normal except for the respiratory rate] should suggest that the patient’s altered mental status is due to [most likely] and attack of acute on chronic ventilatory dysfunction.
Why does Paxil, a serotonin agonist help Paula? It is easier to understand this if one looks at the literature on breathing and serotonin. Perhaps this paper should be renamed Serotonin receptors; guardians of stable mental status in people like Paula with invisible and unlooked for and unexamined ventilatory disturbances. Perhaps this is why serotonin agonists do not work for all people with depression or bipolar illness; they may only work in bipolar patients with altered mental status from ventilatory disorders. It would be nice to know who could benefit from activation of serotonin pathways and who wouldn’t.
Disturbances of breathing arising from failures of the respiratory center are not uncommon. Among them, breath holding and apnea occur most frequently as consequences of pulmonary and cardiac diseases, hypoxia, head trauma, cerebral inflammatory processes, genetic defects, degenerative brain diseases, alcoholism, deep anesthesia and drug overdose. They are often life-threatening and fail to respond to existing pharmacotherapies. After extensive research, there is now a reliable basis for new strategies to treat respiratory disturbances by pharmacological manipulation of intracellular signaling pathways, particularly those involving the serotonin receptor family. Specific activation of these pathways effectively prevails respiratory disturbances and can be extended to treatment of life-threatening respiratory disorders in patients. Trends Mol Med. 2003 Dec;9(12):542-8. doi: 10.1016/j.molmed.2003.10.010. Serotonin receptors: guardians of stable breathing Diethelm W Richter 1 , Till Manzke, Bernd Wilken, Evgeni Ponimaskin PMID: 14659469 DOI: 10.1016/j.molmed.2003.10.010
to be continued…………………
to be continued……