Harvard Heart Letter | January 2002 (updated February 2012)
Now and then, the obituary page lists the deaths of an older couple that passed away within a short time of each other. "I bet they died of a broken heart," you might muse with a sad shake of the head. Can that really happen?
Several centuries ago, the answer would have been yes — "griefe" was widely considered a cause of death. Thirty years ago, scientists would have dismissed such a romantic idea. Now we're edging back to yes again, nudged by documented instances of bad news triggering heart attacks, studies tracing the repercussions of bereavement or the aftermath of natural or man-made disasters, and a better understanding of how stress and depression affect the heart.
The heart under siege
Although stories of spouses dying within days or weeks of each other have the ring of urban legends, they're often true. George L. Engel, MD, a psychiatrist who pioneered studying the effects of psychological forces on health and disease, described dozens of cases in a classic 1971 article in the Annals of Internal Medicine. In some cases, the surviving spouse collapsed on hearing the news of his or her partner's death. In others, the survivor seemed to make a conscious decision to die. In a chronicle of a death foretold, legendary New Yorker editor William Maxwell died within a week of his wife after telling a former colleague, "I've decided there's not much reason to stick around, now that Emmy's gone, and I'm doing my best never to take another bite of food."
When it comes to life stresses, burying a child tops the list. Right behind is burying a spouse and adapting to life alone. The loss of a confidant can make the world a chillier, more threatening place, and survivors may have to do things their spouses had long sheltered them from. Several studies of men and women in the year or so following the death of a spouse show higher than expected death rates, with much of the increase due to heart disease.
Other events — the loss of a home, a career, or almost anything one holds dear — can be just as stressful. Traumatic events like warfare or natural disasters also affect the heart. During the Gulf War, on the day that Iraq launched its first missile attacks on Israel, deaths among Israeli adults were 58% higher than usual, even after excluding those killed by the missiles. Most of the excess deaths were due to cardiovascular causes. A similar spike in heart attacks and cardiovascular deaths was observed in the wake of major earthquakes in California, Japan, Armenia, and Greece.
How can this happen?
A sudden, traumatic shock triggers a maelstrom of hormonal activity. Stress hormones like adrenaline and cortisol flood the bloodstream. These messengers speed up the heart rate, increase blood pressure, tense the muscles, and activate immune cells. They redirect blood from the digestive system to the muscles and make it clot more easily. This primitive survival mechanism, called the fight-or-flight response, prepares the body for danger. If the heart is already compromised by atherosclerosis, though, it can set the stage for a heart attack by constricting blood vessels, rupturing atherosclerotic plaque and forming blood clots, or triggering dangerous abnormal heart rhythms.
Some of the same forces are at work in the long-term stress that accompanies a loss or conflict, or in the not-uncommon slide into depression, and here they can be even more deadly. Constantly elevated levels of stress hormones can lift blood pressure and cholesterol levels, interfere with the heart's steady rhythm, and depress the immune system. Stress hormones may also constrict narrowed blood vessels. In a revealing study, Duke University researchers asked 58 men and women with coronary artery disease to wear portable heart monitors for two days and to record in a diary what they were doing and feeling. Tension, frustration, and other negative emotions often led to recordings that suggested inadequate blood flow in the vessels supplying the heart. This condition, known as myocardial ischemia, can give rise to a heart attack.
Depression is another link between stress and heart disease. It can further boost levels of stress hormones and might make the heart less responsive to minute-to-minute signals to slow down or speed up.
Recognizing Traumatic Grief or Depression
Normal grief and depression look very much alike, at least at first. Here are a few warning signals that grief is evolving into depression:
For more information: The American Association of Retired Persons (AARP) Web site has an excellent collection of resources on grief and loss at www.aarp.org/griefandloss/home.html
Sadness and depression take their toll
Grief and sadness can also provoke heart disease in other, more subtle ways. Some survivors are so shocked by their loss, or so preoccupied with financial and legal details, that they stop taking their medications. For some drugs, missing a dose or two doesn't matter. Not taking a cholesterol-lowering medication for a few days probably won't do any real harm as long as it doesn't happen too often. This flexibility doesn't exist for drugs used to control blood pressure, heart failure, and erratic heart rhythms that must be taken once or twice a day. They "wear off" within hours, and so can their protective effects.
Some survivors may find it difficult to maintain a healthy lifestyle. Cooking and eating healthy meals, or taking walks or getting other exercise, may seem to take too much effort. Some start smoking again, or smoke more heavily. Others drink too much, or turn to painkillers or sleeping pills to ease their suffering.
Although most people eventually emerge from mourning, some slide into depression. Knowing the difference between normal grief and traumatic grief or serious clinical depression is a challenge for relatives, friends, and even doctors. A simplified map of the stages of normal grief looks like this:
- An initial shock followed by possibly overwhelming sadness and fear.
- Feelings of anger at being left alone or guilt over things done or not done.
- A gradual acceptance of the death and return to usual activities.
The time it takes to pass through all three stages varies from person to person. Grief experts usually say it takes a year or so.
If grief is an emotional journey, depression is getting stuck in the mud. Early recognition of clinical depression (see sidebar) is crucial for getting on the road to recovery.
How to help
Survivors follow their own internal maps, not the ones charted by "experts." That makes helping a person during this sad and difficult time a tricky task. Some people need solitude to sort out their feelings and don't want the intrusions of well-wishers. Others need companionship so they can talk their way through their grief. Some progress steadily from stage to stage; others get trapped or find themselves moving back and forth between stages.
The first part of helping is keeping in touch, offering companionship or assistance without imposing your own script for grieving. As long as you feel that the survivor is coping with the loss, low-key support may be enough. But if you think she or he is falling into inescapable grief or clinical depression, it's time to speak up and get help from a physician, therapist, or other professional. Prompt recognition and treatment may help limit the personal aftershocks of a death in the family or a traumatic event.