Richard G. Petty, MD

Dying of a Broken Heart

Some colleagues in London have discovered how intense stress may cause severe irregularities (arrhythmias) of the heart that could be fatal.

It has been known for some time that emotional trauma and psychological stress can precipitate cardiac arrhythmia and sudden death through over-activity of the sympathetic nervous system, the system usually associated with “Fight or flight.” It has also been known that people with preexisting heart disease are particularly at risk. This is one stereotype that is true: if someone with heart disease gets a bad shock, they may indeed die. It has been known for centuries that suffering a sudden unexpected bereavement can be a fatal stressor.

It is extremely important to understand how stress can affect the heart, and researchers at the Wellcome Trust Centre for Neuroimaging at University College London and the Brighton and Sussex Medical School have made an important breakthrough that has just been published in the Proceedings of the National Academy of Sciences. Measuring the electrical activity of the brain and heart at the same time, they discovered at the regions of the brain responsible for learning, memory and emotion can destabilise the cardiac muscle of someone who already has heart disease. These areas of the brain can participate in a “vicious cycle” with the heart.

The patients performed the task of counting backwards in sevens, which is for most people mildly stressful.

The researchers discovered that activity in “higher level” regions of the brain such as the cerebral cortex, not only reflected the responses of the heart to stress, but also became involved in a “feedback loop”, often worsening the situation by making the heart muscle less stable.

The regions of the brain responsible for regulating heart function can be unbalanced by stress, and it can be fatal.

It is further evidence that there is a constant “conversation” between the heart and the brain.

It is also the best evidence to date that comprehensive care of people with heart disease must include stress management.

And why wait until it’s too late?

Now is the time to start building your resilience to stress!

Loss, Yearning and Acceptance

Like most doctors over the last forty years, I was raised on the works of Elisabeth Kübler-Ross.

She was a Swiss-born psychiatrist and the author of the influential book On Death and Dying, where she first discussed what is now known as the Kübler-Ross model.

She was born in Zürich, Switzerland, and interestingly was one of a set of identical triplets. She graduated from the University of Zürich medical school in 1957 and a year later moved to the United States to continue her studies.

As she began her practice, she later wrote that was appalled by the hospital
treatment of patients who were dying. She began giving a series of
lectures featuring terminally ill patients, forcing medical students to
confront people who were dying. Her extensive work with the dying led
to the publication of On Death and Dying in 1969. She wrote over 20 additional books on the subject of dying.

She also proposed the now famous Five Stages of Grief
as a pattern of phases, most or all of which people tend to go through,
in sequence, after being faced with the tragedy of their own impending

The five stages of grief are, in order:

  1. Denial
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance

The five stages have
since also been adopted by many as applying to the survivors of a loved
one’s death. Some of us have also applied these stages to the understandng of people’s psychological responses to chronic illness.

As influential as the theory has become, it has not, until now, been subjected to much research.

A study on the stages of grief was published in Journal of the American Medical Association at the end of February by researchers from Yale School of Medicine. The entire article is available for free download.

What they found was that in contrast to the Kübler-Ross model, yearning and acceptance are the two most salient emotions individuals experience after a significant loss.

The study was based on interviews with 233 bereaved individuals living in Connecticut between January 2000 and January 2003. The vast majority were spouses of the deceased and the remaining were adult children, parents, or siblings of the deceased.

The lead author Paul Maciejewski, assistant professor of psychiatry and director of the Statistical Modeling Core of Women’s Health Research at Yale, had this to say:

"We found that disbelief was not the initial, dominant grief indicator. Acceptance is the norm in the case of natural deaths, even soon after the loss. And yearning, not depression, was the most common potentially adverse psychological response."

Yearning is one of the defining features of grief and is an emotion that most clearly reflects the absence of the deceased.

"Yearning is a longing for reunion with the deceased loved one, heartache about an inability to reconnect with this person. Individuals may cognitively accept the death of a loved one, but they may still pine for them and experience pangs of grief  (i.e. yearning)."

According to the study, disbelief, anger, and depression were not as prominent as yearning and acceptance. However, each grief indicator varied as a function of time  after the loss. In partial support of the stage theory, disbelief reached its peak immediately following the loss. Yearning, anger and depression reached their respective peaks at four, five and six months after the loss and acceptance reached its peak beyond six months after the loss.

These feelings peak and begin to decline by six months in the case of a natural death. Those who experienced the loss were more likely to be accepting of the death if it occurred within six months or longer after a diagnosis. The research confirmed what we see in clinical practice: deaths due to trauma or that occur within six months or less of diagnosis cause the most distress.

As Maciejewski said:

"The persistence of negative emotions beyond six months following the death reflect a more difficult than average adjustment and suggests a need for evaluation by a mental health professional and potential referral for treatment."

This is important research that gives all of us some practical guidance on how to understand, help and support people at a time of loss. It is also important to note that the study did not examine the mitigating effects of religious or spiritual beliefs, which we know can help people deal with loss.

After all, funerals are not held for the dead, but for the people left behind.

“Bereavement is a darkness, impenetrable to the imagination of the unbereaved."
–Iris Murdoch (Irish-born Writer and Philosopher, 1919-1999)

Fibromyalgia and Childhood Abuse

There is a small and growing literature about a link between fibromyalgia and a history of abuse, primarily in childhood or early adolescence.

A new study has shown that people with fibromyalgia who had experienced physical abuse in childhood did not have the normal daily fluctuations in the stress hormone cortisol. They also had sudden surges in the hormone as soon as they were woken up, which can be a good stressor. People who had been sexually abused also had this odd cortisol response on being awakened. These findings suggest that severe traumatic experiences in childhood may be a factor in causing hormonal disturbances in people suffering from fibromyalgia. This adds to the growing body of evidence that in women having pain early in the day, there is a high likelihood that the entire stress hormone system does not function normally.

Colleagues from the Department of Psychiatry, UMDNJ-New Jersey Medical School in Newark, New Jersey have reported that women who have been raped are ten times more likely to experience chronic pelvic pain as well as generalized pain.

Another study has found close correlations between childhood abuse and the subsequent development of chronic pain. The link between rape and the subsequent development of fibromyalgia seems to be mediated by chronic stress, in the form of posttraumatic stress disorder.

What this means is that professionals need to consider this:

  1. It is important careful to inquire about any history of past or present abuse or other severe trauma
  2. That empathy and constructive validation of disease and suffering can be very helpful
  3. That dysfunctional pain behaviors and personality traits may be a consequence of abuse together with a lack of resilience
  4. That multidisciplinary treatments including psychotherapy may be the best approach to helping people. Using the methods of Integrated Medicine is often far better than reliance on potentially habit-forming medications.

If we remember that there is more and more evidence of inflammation and other physical problems in fibromyalgia, and that stress and maltreatment in early life can alter the structure and function of specific regions of the brain, what this all shows us is that abuse in childhood can have a long term impact on the way in which both the body and the brain functions.

Revisiting Resilience

“I don’t measure a man’s success by how high he climbs, but how high he bounces when he hits bottom.”
–General George S. Patton (American General, 1885-1945)

Resilience is the process of being able to adapt and to thrive in the face of adversity, stress, trauma, tragedy or threats. A resilient person is les likely to succumb to any of these life events and is less likely to develop mental illness. But resilience is more than a passive strength or resistance to the slings and arrows of outrageous fortune: it is a dynamic capacity that not only protects us, but enables us to turn adversity into strength and an opportunity for growth.

Despite our extraordinary health care system and a multi-billion dollar antidepressant industry, the rates of depression are increasing throughout the Western world. A recent book has suggested that boredom was unknown before about 1760: the beginning of the Industrial Revolution. All this tells us that something is seriously wrong with our resilience.

“The measure of a man is the way he bears up under misfortune.”

–Plutarch (Greek Biographer and Priest to the Oracle at Delphi, A.D. 46-c.120)

In Healing, Meaning and Purpose, I pointed out some of the incredible changes that have taken place over the last one hundred years, and their impact on health. To try and apply the principles of the past to the problems of the present and future is unlikely to be crowned with success. We need to adapt. Buddhists do not normally eat meat. Except for Tibetan Buddhists, who need to eat some meat in order to survive at the high altitudes of the Himalayas. I have a good friend who created the finest integrated medicine clinic in the world, the Hale Clinic in London. Normally an abstemious vegetarian, when she was embroiled in business meetings, she would often take some meat to remain grounded. I have done the same thing myself for years. I prefer not to eat meat. I have not had a steak in more than thirty years. But if I am to do a lot of traveling and need to work with politicians and business people, a bit of chopped up fish or poultry can be essential.

The changes in our lifestyles over the past century have dramatically reduced the level of physical activity necessary to provide life’s basic resources: our effort-based rewards that are intimately involved in the regulation of mood. If you think about it for a moment, if your great-grandparents wanted to eat, there was probably a lot of effort involved. Our brains still contain a huge number of circuits that evolved to play roles in sustaining the kind of continuous effort that would be critical for the acquisition of resources such as food, water and shelter. So what happens when we suddenly on longer need much physical activity to obtain those resources? What happens to those parts of the brain that have millions of years evolving? There will be reduced activation of those brain regions essential for reward, pleasure, salience, motivation, problem-solving, and effective coping strategies. The practical consequence of that is that these systems will not sit there idling: if under-stimulated, since these systems are so heavily involved with our emotions, we would expect to see people becoming depressed. And we know that depression has been increasing throughout the Western world. Of course, many people need to stimulate these regions of the brain artificially, as with drugs, pornography or extreme sports.

Effort-based rewards are an essential component of resilience to life’s stressful challenges. Purposeful physical activity is important in the maintenance of mental health. It therefore makes sense to put more emphasis on preventative behavioral and cognitive life strategies, rather than relying solely on psychopharmacological strategies. Our strategy is geared toward protecting people from developing depression, and compensatory behaviors. One of the very interesting new ideas in pharmacology is that antidepressants and antipsychotics may act to enhance resilience at both the cellular level and in the whole person. This is a very different concept from thinking of medicines as chemicals that simply block symptoms.

Our aim is to improve resilience and gradually to increase activation of all those under-used systems of the brain to treat and then to prevent problems. All the things that mother always said were good for you: healthy exercise, meditation, a balanced diet, charity and kindness, and actions aimed at fulfilling your personal and Higher Purpose have already been shown to treat and to protect.

Here are some proven methods for improving resilience:
1.    Learn to be adaptable: the heart of resilience is the ability to take things in your stride and to be able to surf the ocean of change, rather than trying to hold the hold it back.

2.    Be aware of the blockages in your mind or in the subtle systems of your body that are preventing you from bouncing back form adversity

3.    Attitude: avoid seeing a challenge as an insurmountable problem

4.    Accept that change is part of life: you can do little about it, but you can do a great deal about how you react to change

5.    Ensure that you have meaningful goals that are consistent with your core desires and beliefs, and that you are moving toward them

6.    Do all that you can to work on establishing your own Purpose in life. You can create a purpose for your life, but also be aware that there is a Higher Purpose in you life

7.    Take decisive actions: even if the first action may not be the best one. Any action is usually better than denying that problems exist, and hoping that they will evaporate while you are asleep or watching television

8.    Develop and maintain close relationships. Even if you are not a sociable person, relationships are one of the most potent way of protecting yourself from life’s ups and downs

9.    Look for opportunities to learn more about yourself, and how you react to situations. This doesn’t mean becoming an introvert or a rampant narcissist, but it does mean taking a moment each day to review where you are and what you can learn form things that are or have happened in your life. This is a big subject, but there are many good ways to answer the question, “Why is this happening to me  again?” and from preventing habitual problems and routine self-sabotage. (I shall be publishing an eBook and CD about this crucial topic in the very near future)

10.  Work on developing a positive self-image. I have had some harsh things to say about the excesses of the self-esteem movement, but it has now been replaced by something far more valuable: the science of positive psychology. We have a great deal of empirical data on how to improve a person’s happiness and resilience. Again, we can speak about that some more if you are interested.

11.  Maintain hope for the future. We have done research that has shown that one of the best ways of predicting a positive outcome with major mental illness, or of reducing the risk of recurrent substance abuse is to instill hope. Again, there are techniques for doing this, even when the whole world seems to be against you.

12.  Maintain perspective: do not blow things out of proportion, and remember that this too shall pass.

13.  Take care of yourself, physical, emotionally and spiritually. Listen to yourself: what does your body need? What do you need emotionally? What do you need from a relationship? What do you need spiritually?

14.  Are you giving others what they need from you? If you have a nagging sense that you are not giving a child or a spouse that they need and deserve, it can dramatically reduce you resilience.

15.  Rather than just thinking about and worrying over your problems, or problems that may turn up in the future, get into the habit of thinking of yourself not just as an individual who is going through problems, but as a boundless spiritual being who is learning a lesson.

16.  Never forget to think about the legacy that you are going to leave. Not just to your family, but to the world at large. If you can’t think of one, this is a good time to begin to create one. That is an enormously  powerful perspective on the world and on your problems.

“I am an old man and have had many troubles, most of which never happened.”
–Mark Twain (a.k.a. Samuel Langhorne Clemens, American Humorist, Writer and Lecturer, 1835-1910)

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