Dr. Windsor Ting and Dr. Gregory Fricchione examine the mind-body connection in their remarkable book The Heart-Mind Connection. Research shows that negative emotions can actually cause or worsen heart disease. They say in the back cover that they have useful information for those who have cardiovascular disease, experienced a heart attack, had bypass surgery, or suffer from an anxiety or mood disorder. Matter&Beyond interviewed Dr. Fricchione about this book. Gregory Fricchione, M.D., is an associate professor of psychiatry at Harvard Medical School and associate chief of psychiatry at Massachusetts General Hospital.
Matter&Beyond: What was your motivation for writing the book, The Heart-Mind Connection?
Well, that book was a collaboration with Dr. Ting who is a Cardiovascular Surgeon and it was actually his idea. He's a very enlightened surgeon in that he, over the years of training in a practice as a cardiac surgeon, came to realize that the experience of undergoing cardiac surgery certainly taxed the mind and that the interaction of mind and heart was extremely important for outcomes. If you're a cardiac surgeon and your goal is to improve your patients' lives it became very clear to Dr. Ting that in order for that to happen cardiac surgeons and cardiologists had to be mindful of the fact that patients needed to be emotionally and cognitively intact, and so he asked me to collaborate on this book, and the book focused on the interaction between mood states and cardiac states.
M&B: What is the nature of this interaction? Does the heart affect the mind or does the mind affect the heart?
It's bidirectional. There is an interaction or there is a relationship between mood disorders such as depression, anxiety, anger, and hostility and the actual human heart. The connection between those mood disorders and cardiac function is extremely important. But then also if you go into the experience of having heart disease and you were fortunate enough not to have one of those mood disorders, the experience of having cardiac disease will put you at risk for developing mood disorders. So it's bidirectional. You can start out with heart disease and wind up having your health complicated by mood problems, or you can start out with mood problems and have your health complicated by heart disease. There's an unholy alliance between depression and anxiety on the one hand and heart disease on the other.
M&B: What happens, let's say, if you are someone who has a history of a major depressive disorder? What happens to his or her heart?
Major depressive disorder is a condition characterized by certain clear-cut symptoms, and those symptoms include having a depressed mood everyday most of the day for two weeks or more that includes losing pleasure in life, something we call anhedonia, not being able to take pleasure in normal activities that would normally make you happy. Along with that is loss of interest in things, guilt, or feelings of hopelessness, helplessness and worthlessness, loss of energy, loss of concentration, loss of appetite, sometimes even leading to weight loss, not being able to move the way you're used to.
So it's sometimes you just curl up in bed and this is something we call psychomotor retardation or withdrawal. On the other hand sometimes depression makes you agitated so you can't sit still and you're running around sort of ringing your hands and so on. And then the final symptom of major depression is suicidality or morbid thinking. Always focused on death or wanting to die. So that's the common sort of a cluster of symptoms we see in major depression. Now, say you have no history of heart disease but you suffer from major depressive disorder. You increase your risk of developing heart disease by having this condition of depression. So your risk of having a heart attack for example goes up like 1-1/2 to 2 times what it would be in someone without depression.
M&B: Is it similar with anger and hostility?
Some people believe that if you're an angry person or a hostile person, that also increases your risk of developing depression. Say you have depression and you unfortunately have a heart attack. If you remain depressed then your risk of having another cardiac event, another minor cardiac infarction or a cardiac arrhythmia would go up three and a half times what it would be if you weren't depressed. So that means that this connection between the brain and the heart, between depression and cardiac disease are tremendously important in terms of public health. Because those two diseases are causing most of the disability that exists, by the year 2020, the World Health Organization predicts that heart disease will be number one and depression will be number two in the entire world. That includes the developed world, the industrialized countries as well as the developing low income countries around the world. So in terms of the book that we did we thought it was important because these two illnesses, first of all feed off each other and cause a lot of heartache in the population but they also are the most important diseases in public health.
M&B: The heartbeat change is associated with love or certain joy. What is the physiology behind that?
Let me preface it by saying that this is the age old philosophical question which Plato and Aristotle sort of debated. Love is an idea as Plato thought. So, is there sort of an idea of beauty and of love that exists outside of the materialistic world? Are we somehow plugging into that ideal world of love as material organisms? Or does it come as a result, as an epiphenomenon of the material world we're living? Does it emerge from the biological material world that we're living? That in a way becomes a philosophical question.
As scientists when we see human behavior, there's something that we do, and it's called reverse engineering. Let's look at the behavior or the experience of human love. Where does that come from? Let's work backwards from human love to try to understand in a biological way where it came from. We are the ultimate mammalian life. We might start a little controversy about that and especially with the all wars that we fight, but be that as it may, we are these high level, high functioning mammals. Our infants are born [in need of] altruism, which means that they are absolutely helpless when they are born. So parenting for the human being is extraordinarily important for the continuity of our species, and so our infants are in total need of care.
M&B: Isn't this the same for all the animals?
It's different in reptiles. If you go to Borneo and you study the life of the Komodo dragon, you'll find out that komodo pups know immediately what they have to do when they plop out of komodo mommy. They have to roll around in their own feces in order to throw mommy off the scent because mommy will look at them as food. So that's their strategy for avoiding being eaten by mommy. They also know how to climb up trees to get away from mommy. So here the survival strategy of reptiles is not one of attachment; it's one of separation.
All psychiatry is tied up in that simple fact. There would be no psychiatry if we were reptiles. But because we're mammals, there's psychiatry because all of the disorders we have are really disorders of a dysfunction in parental and social attachment. Only mammals for example have a part of the brain called the paralimbic cortex. So reptiles have primitive limbic areas, they have hippocampus, they have amygdala, so they show fear, and they act when they're threatened, etc. They're outfitted with those structures which allow them to do those simple attachments-attachments to food and to sexual objects etc., but don't allow them to do social attachments very well, and there's some reptiles that are better at it than others.
Crocodiles, for example. They do a version of taking care of their pups. Birds also take care of their nestlings very well, and crocodiles actually have brains that are more kind of on the bird-like end of the spectrum, allowing them to do a better job as reptiles taking care of their young and having something of a social life. Nothing to the extent that mammals do and you can look at a mammal brain, and you can see where this is taking place. So the anterior cingulate is an area of extreme importance for mammalian behavior.
M&B: This unique mammal feature, the limbic system and the paralimbic system; would you elaborate a little bit more on them?
I had the privilege of meeting back in 1990 Paul McClain, who is a famous neuroscientist who coined the term limbic system. He studied emotional parts of the brain in reptiles and in monkeys and in human beings. He talked about what he called the mammalian behavioral triad. There are three things that mammals do that reptiles don't do very well. One is that all mammalian infants cry for their mothers in the same way, so every lamb baas for its mother the same way. Every human infant cries for its mother in the same way, that's called a separation cry, and you can study it. So when you look at rats they have an ultrasonic isolation cry; you can study it, and you can deprive them of relationships and you'll see the cry. That's typically mammalian. Another feature is play, so mammals play, and that serves a social binding function. We play sports together; it serves a social binding function. Then the third thing is maternal nurturance which is extremely important, and mammals do that parental nurturance piece pretty well.
M&B: Are there any experiments that may illustrate the role of love?
There are a couple of experiments that Paul did and they are very illustrative. They get us back to a focus on love. So one experiment was to take hamsters and you can ablate, sort of take out the anterior cingulate. When you do, the hamster pup no longer cries for its mother when it's separated and the hamster mother no longer responds when the hamster pup cries for her. You can also put morphine in that area, and get pretty much the same results. So you could put morphine in the hamster pup's brain in the anterior cingulated, and the hamster pup will no longer cry for their mother, it distorts that bonding. And you can do that with squirrel monkeys too and you'll get similar results.
M&B: Do the results apply to human beings as well? Could the use of morphine stop a healthy heart or brain from giving love or responding to love?
One of the real problems that we face in psychiatry is when we run across an addicted mother. What happens to the mother child relationship when the mother is addicted to heroin or to cocaine or to other drugs of abuse? The child gets neglected, the mother no longer responds to the needs of the child. So we see there's even a reflection of those basic experiments in the human model when we're talking about maternal-child relationships. So again that's kind of circumstantial evidence where there's reverse engineering, and mothers also have this phenomenal hormone, neuropeptide hormone, this again is exclusively mammalian, called oxytocin. So it's used in pregnant women to get them ready to give birth, and so once a pregnant woman gives birth it's responsible for milk production and so on. This is another example of this – if we think about maternal love, one of the requirements for maternal love is that there needs to be oxytocin involved. Oxytocin needs to allow that brain to have the experience of being connected and bonded to offspring.
M&B: The relation between the brain and the other organs such as the heart, is it really a top down relation where the brain commands, or is it a bottom-up relation where bodily sensors form the human brain?
What you're referring to when you bring up this fact that the body sends markers up to the brain, and the brain takes note of that and becomes behaviorally engaged, that is absolutely true, and it's something that Tony Damasio calls a somatic marker hypothesis of how the brain works. This is also something that William James postulated in the late 1800s-that emotion is a reflection of the body's activity. Your heart racing or your stomach turning, emotion is secondary, it's the brain trying to make sense of what the body is going through. What came first, the chicken or the egg, that kind of a problem. The fact is, the organism works as a unity and you need all of its component parts for it to work, and you really can't tease a part, what came first and what came second.
M&B: From our physiology, it is evident that we are born to love.
It is very spiritual about this kind of understanding of love and connecting it back to the brain. How the heart becomes a reflection of what the brain is about, and also this need we have as human beings for connection. Spirituality really is this need we seem to have as human beings to be connected to something greater than ourselves. So we have this part of our brain, the prefrontal cortex, which allows us to think into the future and when we think into the future, we gain security when we see a future of connectivity, of attachment. That becomes a workable definition of spirituality. So many of us feel connected to a higher power, to God or to nature, but that is also a common reflection of what people refer to as love, and again you can choose to understand its biological origins. The body will be connected up with that whole experience, so your heart will be connected up. If you're feeling connected to God, or to the scene of an ocean, and you're feeling connected to the universe, when you're looking up at the stars, there will be a bodily sensation connected up with that experience, and that will become for you part of what you understand to be spirituality.