• On “Broken-Heart Syndrome” and the Possibility of Resilience

    After a Divorce, Florence Williams Considers the Connection Between Heart Health and Love

    The heart can break in a lot of ways. It took a while for the cracks to form in mine toward the last hard years of my 25-year-marriage. But sometimes loss happens all at once, so suddenly that the heart literally stops working. Interested in the links between one’s emotional state and one’s physical health in the wake of my divorce, I read up on a condition called Takotsubo cardiomyopathy.

    Sometimes called “broken-heart syndrome,” Takotsubo is brought on by sudden distress in otherwise healthy people. Although it’s been long known that emotional shock can cause heart failure, it wasn’t until 1990 that Japanese researchers were able to use new imaging technology to reveal an unexpected signature of illness, and it wasn’t until 2006 that the American Heart Association formally recognized the condition.

    In Takotsubo, patients appear to be having a regular heart attack, presenting with chest pain, fluid in the lungs, shortness of breath, and compromised heart function. What makes these attacks different is that the arteries are free from the typical blockages that cause cardiac failure. Instead, a portion of the left ventricle—the heart’s main pumping chamber—wildly underperforms, causing it to balloon in compensation. No longer a neat fist, the heart now sprouts a weird distension like an overeager blister. Doctors named the condition Takotsubo after the Japanese lobster trap, which has a narrow neck and bulbous head. In this kind of cardiac event, the heart cells don’t necessarily die, but they give up for a while. Approximately 5 percent of patients don’t survive the initial event.

    Takotsubo, which appears to be caused by a sudden rush of stress hormones stunning the heart, represents about 2 to 7 percent of all sudden cardiac hospital admissions, but the actual incidence may be higher (diagnostic images aren’t always taken). While most patients recover within a couple of months, about 20 percent will suffer complications, including heart failure, arrhythmias, scarring of the heart muscles, and premature death.

    Like grief and shock, the condition can be shared, reflecting the many reasons the heart breaks. We can experience the collective grief wrought by war, violence, and natural disasters, the grief of losing species and habitats to which we feel deeply akin; there’s the collective and individual grief of racial and social injustice, the individual grief of core relationships blown up through death or chronic illness or by someone’s choice.

    After a major earthquake in the Niigata Prefecture in Japan in 2004, researchers found a 24-fold increase in Takotsubo cases within four weeks. In 2011, researchers from the University of Arkansas examined 22,000 cases and found spikes in Vermont, which had suffered lethal, unexpected flooding, and Missouri after the Joplin tornado. And an Ohio study found a 4-fold increase in cases during the Covid-19 pandemic (the patients did not have Covid).

    The case literature of Takotsubo patients includes recent widows, women whose children or pets just died, and people undergoing other extreme stressors. One woman reportedly suffered Takotsubo after accidentally eating a huge amount of wasabi. One 56-year-old man was found to suffer from Takotsubo after his favorite soccer team lost the 2012 European Cup in Poland. He made a full recovery. After Chile flubbed the last penalty kick in a championship match against Brazil in 2014, a 58-year-old man went into classic cardiac arrest, in which something, typically high blood pressure brought on by emotional or physical stress, causes a piece of plaque to break loose and block a major artery. He was rushed to the hospital, where he died.

    A little over an hour later, his 64-year-old wife collapsed with chest pain, tightness, shortness of breath, and heart failure; she was experiencing Takotsubo. She survived. (As Bill Shankly, the former manager of the Liverpool Football Club, once put it, “Some people believe football is a matter of life and death I can assure you it is much, much more important than that.”)

    Science bears out the close relationship between heart health and love. Karl Pearson, the British founder of biostatistics, examined gravestones in the early 1900s, noting that husbands and wives often died within a year of each other. More recent research shows that people unhappy in love— either in bad relationships or in broken ones—suffer higher rates of heart disease. A survey of 43 million medical records in Denmark found that in the year following a romantic breakup, men between the ages of 30 and 65 experience a 25 percent increased risk of a heart attack, and women experience a 45 percent higher risk. In both sexes, the risk remains elevated by 9 to 24 percent even nine years later. Love protects your heart, while loss weakens it, sometimes forever. As physician Sir William Osler put it in 1908: “The tragedies of life are largely arterial.”

    With all the grief going around these days—whether from foiled love or global contagion or social injustice or the climate or a host of other things—it’s a wonder more of us don’t collapse from the emotional toll. Why don’t we? There are many reasons to love estrogen. One of them is that it protects us from sudden shock, which is why 80 percent of Takotsubo cases occur in postmenopausal women. Perhaps evolution designed it that way so women’s hearts wouldn’t seize up during our highest and scariest exertion event, giving birth, when our estrogen levels are through the roof. But after the childbearing years, good luck.

    Martin Luther once said, “Faith resides under the left nipple.” Takotsubo is the metaphor of a broken heart made real. It renders obvious a truth that is more subtle: our bodies want us to feel safe and to feel loved. What happens to us when we lose that attachment is a central theme of this book.

    I wanted to learn more about what had happened in Joplin, Missouri, on May 22, 2011, when an EF-5 tornado ripped through town. As someone interested in the therapeutic benefits of nature, I was especially curious about the butterfly garden created to help the community heal in the wake of loss and grief. And I’d also heard about the uptick of Takotsubo cases. The wrath of nature was causing literal heartbreak, which was in turn salved by nature. I reached out to a man who became caregiver to both wounded trees and wounded people.

    On that fateful day, Chris Cotten had been on the job as the city’s director of Parks and Recreation for just 86 days. In the afternoon, he visited Lowe’s, picking up fencing material for his family’s new yard. Just west of him near the Kansas border, a bulwark of thunderstorms traveling northward from the Gulf of Mexico had crashed into a cool mass of air traveling south from the jet stream. By 4:12 p.m., three churning supercell thunderstorms were generating strong wind shear as warm layers of air rolled over cooler winds near the ground. A rotating mesocyclone tipped into vertical position as it continued on its inexorable path eastward toward town.

    Cotten’s wife and four kids were safe outside of town. He made it back to his house and watched the sky churn yellow as huge balls of hail dropped onto his truck. He heard the sirens. The air smelled funny, of chemicals and underlayers of soil. It was the smell of destruction. By 5:39, anyone who was still outside could see the three-quarter-mile-wide twister that had formed into a perfect, horrifying, prairie-eating comma. He waited until it grew quiet, then he headed out to inspect the tree damage to the parks under his care. But he couldn’t even find the parks. Instead, he saw entire neighborhoods flattened, roads cluttered and unrecognizable, debris everywhere, and people shrieking.

    An EF-5 tornado is as bad as it gets. It is also incredibly rare, making up about one-tenth of 1 percent of all tornados. The storm had taken its time ripping up Range Line Road, a major thoroughfare, taking a number of stores and businesses with it. At the Home Depot, the roof had popped off like a soda can tab, knocking over the store’s walls like falling dominoes, killing seven people. The tornado lifted St. John’s Regional Medical Center four inches off its foundation and knocked out all the complex’s power systems, killing a half dozen people on life support.

    As a city employee and former lifeguard with first-aid experience, Cotten gathered another park worker and together they converted a public hall into a triage hospital. For the next 48 hours, Cotten carried in bloody bodies, laying them in rows on the stage. He sorted out the injured for medevacs, then assisted surgeries on banquet tables, then ran out to perform search and rescue. Zipping the body of an older man into a bag, he watched parts of the man’s brain fall out. He pulled roofing tacks out of a kid’s back and listened to a bloodied girl screaming Please stop over and over again. The traveling Piccadilly Circus was in town. At one point, it offered up two adult elephants to help remove heavy debris from the roadways to clear a path for first responders and the arriving National Guard.

    Eventually, the death toll would reach 161, the worst in the US since a 1953 tornado tore through Flint, Michigan. Cotten did finally assess the tree damage: 18,000 gone. Some of those still standing were completely debarked.

    Many of the survivors testified to their faith in God, the compassion of neighbors, the trauma, the exhaustion, the grief. But others spoke of something more surprising: the presence of butterflies, spectral and protective. A little girl recounted how her father had lain across her in the yard grasping at the sod. His shoes were pulled from his feet. When the storm lifted, leaving them unharmed, she said, “Daddy, it was okay, a butterfly was holding us down.” Another girl who was lifted into the air described how a butterfly wrapped its wings around her and brought her back to earth. A child who emerged unscratched from a car filled with glass and debris described a similar experience in recorded accounts.

    Chris Cotten knew what to do. He took a park and residential street at the epicenter of the devastation and turned them into a place of healing: a butterfly garden. Today, the site features black steel posts and beams that create 3D outlines of the houses that once stood there. Sedges and small shrubs provide habitat for prairie butterflies, and a journal sits attached by a chain to a bench where people can sit, reflect, and write. And of course, there are the trees, thousands of them, newly replanted. Cotten’s team received input not only from the community but from the emerging field of “resilience studies.” As someone looking for lessons of resilience, I was eager to learn more.

    Keith Tidball, a researcher and fellow at Cornell’s Atkinson Center for a Sustainable Future, who worked on the project, told me he is interested in two kinds of resilience: ecological and psychological. Often, he says, the two are intertwined. A natural disaster, or a human-caused one, like a war zone, leaves both people and landscapes ravaged. It’s not uncommon for people in affected communities to suffer from post-traumatic stress, grief, depression, anxiety, rumination, and suicidal thoughts. In the worst disasters, up to 30 percent of the local population may show some of these symptoms for a period of time, with children being the most vulnerable. Tidball studied the effects of tree planting on traumatized residents in New Orleans after Hurricane Katrina. He found the saplings became symbols of ecological and social renewal, a response to the narrative of New Orleans as a failed, broken city. The civilian acts of planting served as gathering opportunities, and the trees themselves became icons of resurrection.

    “The loss of trees is a major heartbreak and disruptor,” he said, “so the act of stewarding them back is fundamental to recovery.” In a crisis, nature reminds us that we are not the center of everything, and also that we are all connected.

    Often people don’t even realize how much they love and need the trees until they are gone. Tidball calls this yearning “urgent biophilia,” and it was a phrase that kept coming back to me. We need the bosom of the natural world, and sometimes we need it now, and in every town and in every neighborhood. After heartbreak—whether over a devastated landscape or a personal loss or a global crisis like a pandemic—it is often nature to which we turn. The more uprooted we feel, the more we need the literal rootedness of things with roots.

    “When you hurt, nature heals, and that’s what this is about,” said Tidball.

    At the five-year anniversary of the tornado, hundreds of people turned out at the Butterfly Garden & Overlook for a children’s fun run, a silent hike, a community picnic, and commemorative talks. Chris Cotten was not one of them. He moved to Kansas after the park was dedicated in 2014, and he can’t bring himself to go back.

    “I just couldn’t deal with the tornado anymore,” said Cotten, who, like many first responders there, has undergone treatment for recurrent nightmares, anger issues, and anxiety. Last year, his marriage unraveled, more collateral damage from the tornado, he said. He had become emotionally withdrawn and distant. Rebuilding the parks took over his life; he wasn’t there for his family, he said.

    Perhaps because he worked so hard to make a healing space for other people, the garden just didn’t bring him peace. “I take comfort that it helps other people,” he said. “But I don’t know if I’ll ever take comfort or get over what happened.” As bad as the storm itself was, he said the trauma of his divorce was just as bad.

    “Really?” I asked him.

    “Yes,” he said, explaining that both experiences clashed and magnified, much like the storm cells on that May day in 2011.

    It was a sobering thought that made my stomach sink in both dread and recognition. I didn’t have to live through a literal tornado, but it was clear that for many of us, heartbreak tears up all familiar terrain, leaving behind trauma, physiological chaos, and a shattered identity.

    Nature appeared to be helping Emma recover, but it wasn’t enough to help Chris Cotten.

    Would it help me?

    I hoped so. I didn’t really have a lot of other ideas.


    Excerpt adapted from Heartbreak: A Personal and Scientific Journey. Copyright © 2022 by Florence Williams. Used with permission of the publisher, W. W. Norton & Company, Inc. All rights reserved.

    Florence Williams
    Florence Williams
    Florence Williams is the author of Breasts, winner of the Los Angeles Times Book Prize, The Nature Fix, and Heartbreak. A contributing editor at Outside magazine, her writing has appeared in the New York Times, National Geographic, and many other outlets. She lives in Washington, DC.

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