Welcome to Chasing Life. We have a very timely and I think very important episode for you today, especially given that Valentine's Day is around the corner, love is in the air. That's a good thing for most people. But for a lot of people listening, they know it can be a painful thing as well. And not just sort of emotional pain and not even mental pain, but actual physical pain that sometimes accompanies love. Sometimes, it's part of what makes love so unique, so special. But sometimes pain is just pain and it's something that we have to deal with. That's part of the reason I'm so excited to have Professor Yoram Yovell on the show today. He is a psychiatrist, he's a neuroscientist, he is someone who's experienced some of the most difficult mental pain one can experience in their life and he dedicated his life to understanding it and treating it. Why does heartbreak sometimes hurt? Literally. Why does it occur? Why are we human beings evolved to feel that kind of pain? I'm Dr. Sanjay Gupta. This is Chasing Life.

I'd like to start with the story that you talk about in your TED Talk. And it's a bit of a, it's painful story, which I guess is part of what we're talking about today. But when you were 14 years old, you lost your father. First of all, I'm sorry, at such a young age to lose a parent. What was that experience like for you?

It was awful. He was my hero. You know, I can still remember how much it hurts.

Could you just share a little bit what happened with your father? Was it a sudden sort of thing or?

He had, it shouldn't have been as sudden. He got cancer at a very young age and he was a doctor himself. And I think as like many doctors, he kind of denied it, didn't get checked. And once he was diagnosed, it was really too late. He was stage four and he died a short time after he was diagnosed.

Can you talk about that pain? Like people describe pain, they'll say, you know, my ankle is injured, whatever, but what was this pain? What did it feel like?

It felt like this crushing, like something heavy on your chest. It just hurt and I remember it still very clearly. It stayed with me for a very long time. It doesn't feel that way anymore. When I think about him, I can still feel a little twinge, a little pang of it. But in real time, it's awful. You know, I think you know just do that little experiment and ask someone, you know, what's the most painful thing that ever happened in their lives and I think most times they would not tell you about a motor vehicle accident or some surgery, but they'll tell you about someone they loved and they lost. And I think that's no coincidence. The pain matrix in our brains also mediates what we call mental pain, I mean it really is pain.

People have chest pain, their stomach may feel a knot, muscle pain, you know, things like that as a result of some deeply emotional experience. What exactly is happening in their body?

Well, most of the action is happening in their brains. You know, we know that you can have terrible pain in an organ that doesn't exist anymore. You know? Phantom take, take phantom pain.

Right.

You know phantom pain is someone that's had their leg amputated 20 or 30 years ago and they're still suffering terrible pain in the toes that they no longer have.

I remember reading a study some time ago about loneliness and put these, these patients in a functional MRI scanner and they were trying to basically look at areas of the brain that they know are responsible for physical pain and see if some of those same areas were lighting up in someone who's experiencing loneliness and they found a significant overlap. So when you were experiencing something that would, I think, definitively be thought of as an emotional experience, to see the idea that the brain is lighting up in the same way, is that the mechanism you're talking about?

'Yes, so that the mechanisms, they really do overlap. And I think really that mental pain actually serves the same function that physical pain does. It's an alarm system, right? You know, acute pain alerts us to situations where there's tissue damage. And chronic pain is when that alarm system sort of works quote-unquote too well. It keeps on ringing even when that doesn't serve any any survival function. I think acute mental pain is also an alarm system. It means that we're about to lose a connection to someone we love.

Like, why did we human beings evolve to feel, as you describe it, physical pain in response to these emotional things?

We know that from the experiments of Jaak Panksepp, who was a basic neurobiologist who worked with animals, and he was the first to realize that separation anxiety serves a survival purpose because then they seek out their mothers and they yell and they yelp and that brings them back together. And that's essential. Because baby mammals can't survive on their own in the wild. And actually, most mammals lose that capacity, they lose that sensitivity as they grow older. But social animals like dogs, wolves, primates, they don't lose it. They keep it all their lives and we do too. So we have the capacity to form intense attachments and also to feel very distressed when we're about to lose them. We have that throughout life. And if you ask what purpose does mental pain serve, and I have to say it in just two words, that would be 'superglue'. It's that pain that we feel when someone's about to leave us that brings us back together. And I think that's what holds us together in couples, in families, in extended families. We know that because we know what it feels like when they're gone, you know? It's one of those questions that poets and philosophers ask, does love always hurt? And I think, you now, the answer is yes, of course. It doesn't mean love is usually beautiful, right? But at some point, love is going to hurt. And if it doesn't, then it might not be love.

Wow.

If you don't feel pain when someone you love is separated from you, then you know, love may have already died.

Wow, that's really interesting. I mean, you did say that that sort of pain does decrease in humans as we get older, right? I mean when they were younger, you know, teenagers falling in love and then breaking up, that seems like a much more dramatic event in some ways.

Right, absolutely. I would say this that it's not so much that the mechanisms that produce the pain are dampened or dulled, but it's that we have more techniques and we have better mental tools to confront the pain and to make it go away. And I think this is what's so heartbreaking in children. They feel the pain, but they don't have the maturity and the sophistication and the knowledge and the perspective that adults oftentimes have that can help us get over it.

If you were to do a cardiac heart study of somebody who was saying that they're having this crushing chest pain just after some sort of significant emotional experience, would those heart studies reveal anything? Would they just look normal?

Well, it's interesting, you know, it's relatively rare, but there's this syndrome that you see mostly in women, much more frequently than you see it in men. It's called Takotsubu Syndrome, and that is something that mimics acute chest pain, and it manifests differently. And it very frequently follows an emotional turmoil and they used to miss some of the women who would come into the ER complaining of chest pain and they would oftentimes be diagnosed as having a psychiatric issue, whereas what they really had is they had a variant of this cardiac syndrome. But that's relatively rare. Most people who tell you that they're heart broke, they can tell you, I'm not having a heart attack. I just feel awful because I lost the person I love.

So you know, I got to tell you, one of the more painful experiences of my life was actually losing my grandmother, who was sort of the matriarch of our family, someone who, you know, just was so selfless and so giving of herself to everybody that it was hard to imagine our family without her. And there was a particular moment, which happened sometime after her, she passed away, we were cleaning out her apartment. And I had, she always loved crazy socks. You know, when she was younger, she wore very brightly colored socks. And I bought her this pair of brightly colored socks years earlier. And I found it in her apartment when I was helping clean it out and it was still in the wrapper. She had never opened it. And what was so striking in the Indian culture, Yoram, is it's almost like when women lose their husband. In the Indian culture, they take this vow of austerity. They take this vow of grayness. Everything about her changed after my grandfather died. She only wore white clothes. She stopped dyeing her hair. Even her glasses, she bought clear rims. No color in her life at all. She never opened those brightly colored socks. That was the moment that I felt the chest tightness. Like this is how she lived her last years of life. But I think how people deal with death in different cultures and different places, it varies a lot and sometimes it's really heartbreaking to see unfold.

Absolutely. You're right, it has so much to do with cultural norms, because if to her it would suggest that she's somehow being unfaithful or unloving to the memory of...

Right that just doesn't serve a purpose, culturally perhaps, but in terms of one's own mental health and the idea that they can still have an enjoyable life after the loss of spouse I think is really important.

After the break, we have much more with Professor Yoram Yovell. We're going to talk about some surprisingly effective ways to ease the ache that sometimes occurs during Valentine's Day.

I think one of the struggles is why does it persist in some people? And I think it's the same question, I think with physical pain as well. You touch a hot stove or something, it hurts. And there's a lesson that you learn when it comes to mental pain, as you call it. Why does it last for some people versus others?

I think that acute mental pain is a great thing, you know, it really is. It lets you know who you care about, it can stop you from doing impulsive things, but when it persists it can depress people, it can upset people, and it can even make them suicidal. So, I think basically in psychiatry we're dealing with chronic mental pain, in the same way that in general medicine, uh, we're dealing with chronic physical pain, you know, it's something that we have to try to help people get over. You know, I'm a clinical psychiatrist and I treated patients who were basically, um, dealing with emotional pain and when it gets really you know people become suicidal and most people want to end their lives not because they don't want to live anymore but because they don't wanna suffer anymore. They just have too much mental pain and that's where we're trying to harness our neurobiological understanding in order to have medications that might help people get over that pain without exposing them to all the very grave risks of narcotics. You can treat mental pain with narcotics, that's a fact. There's no question about it.

Wow. In the short term?

Absolutely, absolutely. Actually, I did the first placebo control study. We saw that the people who actually got the very low doses of buprenorphine, they're lower than the doses that clinicians use when they tried to treat physical pain, they really had an advantage in terms of how suicidal they were and how much they suffered mental pain compared to the people who got placebo.

And this is not my area of expertise, but I would have thought antidepressants because I'm thinking this person is having a depressive episode. So antidepresants may be an option, but you're saying actual pain medications for someone who may have heartbreak, so to speak, after loss.

'Yes, yes, yes...Naomi Eisenberger from UCLA, and she did some work with undergraduate students experiencing the ups and downs of romantic life on campus, and she did a placebo control study where one group of students got just regular Tylenol, you know, 325 mg twice a day, and asked to quantify how much mental pain there were. That the people who are on Tylenol had less trouble negotiating those rejections of everyday life. So that's nice, except that works when it's not really severe. When it's really, really severe then Tylenol is not good enough again. So going back to the antidepressants versus opioids issue, there definitely is a role, and it's an important role, for antidepressants in treating chronic pain. But it's often not enough because there's that opioid pathway which is not adequately covered by antidegressants. I'll give you an example, in that study, as I told you, we didn't stop people from using antidepressants if they were using them. And we looked at the people who were on antidepressants and on people who were not on antidepressants and it turned out that there was no quote-unquote advantage to the people who are taking antidepressants.

That's interesting.

So we know that that quality of pain is probably something that's mediated more through the endogenous opioid pathways rather than through the serotonin norepinephrine pathways.

That's really interesting. And I think it's worth just pointing out at this point that when we talk about pain, just as a general term, there's probably always a component of both physical and mental pain. And so I think people are surprised sometimes when you hear about things like antidepressants being used to help with physical pain. And it's not just because there's these overlapping mechanisms, it is because there is a mental pain component to it. So I just want to flag that point for the listeners, pain is complicated that way. So pain medications that people typically think of may be inadequate, but at the same time, antidepressants may be adequate when it comes to mental pain.

Right. Absolutely, right.

As we talk about Valentine's Day, you know, obviously love is in the air people are talking about it. But at the same time there may be a significant percentage of people who are in relationships that probably aren't the best relationships for them. But the problem is that it hurts, even physically, to consider breaking off that relationship. It hurts to consider that separation. But that may be the right thing for them to do at the time. And yet there's this biology which is preventing them from doing it because of the pain. What do you recommend in those situations?

One of the things that helps most, and this is really important for Valentine's Day, is reconnecting to other people that you love. And that's key and that's crucial. And if we don't do that, people can stay lonely and hurting, and they're not going to break out of that shell because they're trying to avoid anything that might potentially hurt them anymore. It's very, very hard to get people to give up an abusive relationship, but if we have someone we love who we think is in a clearly abusive relationship then I think it's our job to be there for them and to let them know what we think and to support them as they go through it. Sometimes they have to go through a lot before they're ready to make that step.

Earlier, you said, you know, someone goes through a breakup and it's not that painful for them, it may be an indication that there wasn't as much love in that relationship. And yet I hear stories all the time of people in abusive relationships or just terrible relationships, but they stick with it. Why do they stick it in a situation that's clearly detrimental to their mental if not physical health?

'What we know as an anxious-dependent attachment style in infancy predisposes you to have these kinds of maladaptive attachments in adulthood. We know that children who have been neglected or abused in certain ways are tragically more prone to get into abusive relationships in adulthood and once they're in them they're going to be less likely to leave. And basically I think that as physicians, as therapists, as family members, the victim, treat all the treatables, treat whatever you can treat. Reach out to those people, try to take them out, tell them what you think, be there for them, show them other options. Don't lose heart if they push you back and keep bouncing back.

'But I do think, you know, you run into these situations where people outside of that can look at it and say, this is not a good relationship. It's not a healthy relationship. And yet the person persists. It almost makes you at sometimes wonder, do they not see themselves as worthy? Do they not have a high degree of self-worth?

Uh look it's tough. You're right, these are mysterious things. People are magically attracted to people who are not that fond of them, right? That's the old Groucho Marx saying, right, I refuse to join any club that would accept me as a member. And I think in love, often times you do see that, that people are going for people who don't treat them that nicely.

Can I ask you something? Because I have three daughters...

Me too. Haha.

You have three daughter? We're blessed, I think, right?

Yeah, yeah. Also I have two sons and then three daughters.

Oh wow, that's amazing. Big family. But you know, so much of my life now, probably yours as well, is as father. So I think about my three daughters and if they're in a relationship that's not great, you know, at what point do you step in? By the way, if they are listening, because they listen to the podcast, I'm not suggesting that any of you are in relationships that are not great. I'm just saying that it is a worry for parents. I mean, if clearly a loved one is in a terrible relationship, what do you do?

Yeah. Well, first of all, I'm smiling because my three daughters are younger, so they're not there yet. You know, the oldest of the three is 14. And you can imagine, you know, what we're going to go into in the next few years.

Well you can call me if you want some tips, Professor. I'll be there for ya. I'm a little bit ahead, I got 20, 19 and 16, so feel free to reach out.

Wow. Yeah, yeah, yeah. I'm sure you have great stories.

You know, I mean, again, I think people who are listening are gonna hear a conversation like this and interpret it from their own lens, right? I mean do you have any, any guidance?

The question for us as parents and actually the question for us as clinicians as well is when to intervene and when to just let nature you know play out and, and have people learn what they need to learn and it's a tough call it's not easy. I think most of us eventually get it and you know find the kinds of relationships that can really bring joy and happiness into our lives. You know, this is Valentine's, we shouldn't forget it. I think really for most people, the best prize that life has to offer is an intimate relationship with someone you love for the long run. You know, it doesn't get much better than that. It's worth everything. But sometimes you have to go through a lot of trouble.

Go through trouble, maybe some trial and error. You know...

Yep. You know, there's this old Burt Bacharach song, "I'll Never Fall In Love Again". Right? What do you get if you fall in love? I'll never fall in loved again...

"...for at least until tomorrow, I'll never fall in love again..."

I used to work hard on my patients to convince them to go back on social media and try to meet someone after they've suffered a separation or a disappointment. I would tell them the heart is strong, it hurts, it's true, but the heart can heal and there's still people who love you and you should reach out into the world and most of us do it.

Well, that's beautiful, Yoram. Thank you so much for this and your time. I think it's a very important message around Valentine's Day and really appreciate it. Thank you.

Thank you, it's been great talking to you.

That was psychiatrist and neuroscientist Professor Yoram Yovell. Look, I know heartbreak can hurt and Valentine's day can sometimes make it feel even more intense. But the good news, the good new, There are definitely ways to help yourself through it. And help the ones you love as well. Thanks so much for listening.