When heart disease wears a smile

by Carolyn Thomas      @HeartSisters

I love this photo of three generations of our family, taken during the weekend of my late mother’s 80th birthday. That’s her on the left, me in the middle, my daughter Larissa Jane on the right. Happy smiles all around – yet one significant problem:  I was very, very ill while smiling for the photographer. In fact, I was admitted to the hospital the day after it was taken.  And this time – unlike my first trip to the Emergency Department two weeks earlier –  my “widow-maker” heart attack was appropriately diagnosed and treated.         .            .  

I like to show this picture to my Heart Smart Women audiences. It’s a graphic portrayal of how women’s heart attacks may not resemble our stereotype of what a heart attack “should” look like. You know that stereotype: old guy out on the golf course, suddenly clutches his chest in agony, falls down unconscious (which is, by the way, not likely a heart attack at all, but sudden cardiac arrest). In my case, however, I could walk and talk and think and drive my car and go to work and get on a plane to fly across the country for my mother’s birthday – and smile during a photo shoot (despite severe symptoms that had already been confidently misdiagnosed by an Emergency physician as acid reflux).

What I didn’t know about until much later is what’s known as the slow-onset” heart attack.  In a study published in the Journal of Emergency Medicine, for example, Dr. Sharon O’Donnell looked at the phenomenon of slow-onset symptoms in heart attack survivors.(1)  Her team found that 65% of the 900+ heart patients admitted for cardiac care had presented to Emergency with slow-onset symptoms – and not the fast-onset stereotyped crisis we see portrayed in the movies.  In the movies, a heart attack (almost always in a white-middle-aged male person) occurs swiftly with agonizing symptoms that worsen with every passing minute.  But for many real-life heart patients, our slow-onset cardiac symptoms can sometimes come and go – and come back again over hours, days or even weeks until they become unbearable.  See also: When Heart Attack Symptoms Disappear – and Then Return

Consider the interesting concept that psychologists call emotional labour, described as the suppression of feelings to provide a welcoming outward appearance to others. (Sound familiar, heart patients? That term perfectly captures my own behaviour during those two fateful weeks before I finally dragged myself back to that Emergency Department). 

This reluctance to look as bad as we feel is not limited to the cardiac event itself. I wrote here about women who routinely dress their best, carefully apply make-up, and paste on their smiley faces so they’ll look better for their doctor’s appointment. 

As Alisha Bridges wrote in her HealthCentral column:

“How many times has the doctor asked ‘How are you?’ and you give the expected response of ‘I’m fine.’  But deep down inside, you are stressed, overwhelmed and concerned about your condition. Stop doing this. Be honest and upfront with your doctor! Be transparent!”

Psychiatrist Dr. Rebecca Lawrence wrote a recent essay on smiling through the pain for The Guardian in the U.K. in which she explained that when her own patients who suffer from depression arrive in her office wearing a big smile, “even psychiatrists like me can be deceived:”

“A cheerful demeanour can be profoundly misleading. Beware the false reassurance of the smile. Appearance is less helpful a diagnostic tool than we have been led to believe. By the time ill health is outwardly obvious, it’s probably very bad indeed. The lesson for all physicians? Listen to people. Hear what they say. They may be telling you something their face can’t express.”

While some studies have suggested that forcing a smile may improve our mood, University of Denver research published in the Journal of Personality and Social Psychology found that those fake smiles can make us more miserable, not less:(2) 

“Positive emotional behavior that does not accurately signal a person’s experience – such as a smile that is not felt – may impede social connectedness and in turn psychological functioning.”

Similarly, Michigan State University researchers studying this phenomenon suggested that forcing a smile is actually linked to deteriorating moods, withdrawal from work, and emotional exhaustion.(3)  Trying to suppress negative thoughts, they observed, may make those thoughts even more persistent.  Researchers explained the difference between fake smiling (known as “surface acting”) and its opposite “deep acting” (which can generate authentic smiles by focusing on positive thoughts).

According to Dr. Brent Scott, the study’s lead author:

“Women were harmed more by surface acting, meaning their mood worsened even more than the men and they withdrew more from work. But they were helped more by deep acting –  meaning their mood improved more and they withdrew less.”

This is an important point, because it reminds us that it’s possible – even advantageous! – to feel better by genuine focus on positive distractions, as our Regional Pain Clinic teaches us through our Pain Self-Management classes.  Avoiding a fake smile, in other words, does NOT mean we have to go around sporting a tragic grimace.

Why Do We Force a Smile?

By the time our three-generation family photo was taken, I was barely able to walk five steps without needing to stop.  Yet the pasted-on smile had rarely come off when around others during those fateful two weeks, and I sure didn’t want to ruin my mother’s 80th birthday celebrations. Nor did I ask for help from flight attendants during a five-hour flight back home to the west coast (except just before landing when I asked them to arrange a wheelchair for me at our gate because I knew I couldn’t walk to the baggage claim). Just sit quietly. Don’t make a fuss. And smile. 

After my misdiagnosed heart attack was finally appropriately diagnosed and treated later that day, I was acutely aware of how frightening my cardiac event had been for my family, especially for my two grown children. I felt almost as bad about the worry I was causing my kids as I did about what was happening to me. When my daughter Larissa flew home to be with me after I was hospitalized, for example, her first frantic words to me were: “Don’t EVER do this to me again!”

My medical crisis had already put my family through so much chaos; whenever I was around them, I still tried to consciously act like my old self, my “normal” self, the Mum who was “just fine” again. Our family and friends want – and need – us to get better after a medical crisis like a heart attack. They search carefully for signs that we’re getting “better” fast enough – signs like a nice normal smile.

This kind of deceptive kindness can backfire, however – as it did one afternoon when I was out walking with Larissa. We must have been walking faster than usual that day because a sudden bout of chest pain (caused by my subsequent diagnosis of coronary microvascular disease) forced me to lean against the stone wall we were passing to take a dose of my nitro spray. Although my daughter knew that I had almost daily episodes of angina, and that I always carried nitroglycerin with me everywhere, this was the first time that she’d actually watched me take it during an angina attack. “Mum! Mum! Are you okay?!” she yelled at me while pulling out her phone, poised to call 911.  Luckily, within minutes, the nitro – a vasodilator that helps to relax coronary arteries – worked its magic and we were once again up and walking.

But the episode reminded me that I’d been so successful in hiding my symptoms that my kids almost forgot that I have them.

And as Dr. Lawrence observed in her Guardian essay:

Good presentation doesn’t necessarily signal that all is well. All of these cautions apply to the often long process of recovery, too. Unfortunately, our faces don’t always map our inner feelings.”

Photo: Village Studio, Grimsby, Ontario
(1)  O’Donnell, S. et al. “Slow-onset and fast-onset symptom presentations in acute coronary syndrome (ACS): new perspectives on prehospital delay in patients with ACS”. J Emerg Med. 2014 Apr 11; 46(4):507-15.
(2)  Iris Mauss et al. “Don’t Hide Your Happiness! Positive Emotion Dissociation, Social Connectedness, and Psychological Functioning”. Journal of Personality and Social Psychology. April 2011; 100(4): 738–748.
(3) Brent Scott, Christopher Barnes. “A Multilevel Field Investigation of Emotional Labor, Affect, Work Withdrawal, and Gender”. February 2011. The Academy of Management Journal 54(1):116

 Q:  How often do you find yourself wearing a forced smile?


NOTE FROM CAROLYN:   I wrote more about heart patients smiling through the pain in my book, A Woman’s Guide to Living with Heart Disease , published by Johns Hopkins University Press.  You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher (use their code HTWN to save 20% off the list price of my book)

See also:

“Smile, Though Your Heart is Aching”: is fake smiling unhealthy?

Looking good for your doctor’s appointment: oui ou non?

Do you want the truth, or do you want “Fine, thank you”?

30 little things about my invisible illness you may not know

15 thoughts on “When heart disease wears a smile

  1. Hi Carolyn,
    I am totally outside of everything as I never wear make-up and I truly don’t try to hide when I don’t feel good.

    Mine was truly silent, I was waking at night because I had stopped breathing and with bronchial asthma and COPD I didn’t take it for granted. I was seeing my doctor with an emergency appointment either the same day or the next. She would ask me if I sat up, did it go away? I sleep flat on my stomach and would have to get up and use one of my inhalers before it would return. She would then then have the nurse do a 12 lead EKG and it came back clear, it showed no abnormal problems. After 6 months of my calling my doctor he would have me come in immediately and they would do an EKG, she’d check it and it came back the same.

    My cardiologist noticed that each time he mentioned her name, I had an attitude. He told me he had seen all of them and they were normal and if he had seen me he would have done nothing different. He let me know that she had done a number of other tests and all came back clear.

    Therefore no indication of a cardiac problem.
    Take care,

    Liked by 1 person

  2. Very insightful. I was misdiagnosed for 6 months partially because of a weird symptom ( water brashing) that leaned the diagnosis towards hiatal hernia and my GP not examining possible heart involvement causing my chest pain. I had no fatigue, SOB or sweating but my symptoms paralleled those of hiatal hernia.

    I ended up needing a quadruple bypass open heart surgery at 60 yrs old and have residual mild angina every day when walking, but seems to be improving. It was suggested I might also have Microvascular disease so this was good information – though I have definite blockage and risk factors for CAD.

    It seems to be a disease for non-blocked pts?

    Liked by 1 person

    1. Hello Lori – thanks for weighing in here. I had to go look up ‘water brashing’ as I’d never heard of that symptom before (= hypersalivation, sometimes seen as a symptom of acid reflux).

      Six months is a long time to wait for an accurate diagnosis and quadruple bypass surgery! I’m not a physician so can’t comment specifically on your situation, but I can tell you that I’m a person who did have a fully blocked coronary artery (causing my heart attack) and was also subsequently diagnosed with MVD. After my heart attack I had ongoing severe chest pain, shortness of breath, crushing fatigue and other symptoms – finally diagnosed about 7-8 months later (including another hospitalization and another trip to the cath lab where no additional blockages were found).

      MVD used to be called a “trash basket” diagnosis – NOT because it doesn’t exist, but because it’s typically arrived at only after all other possible cardiac diagnoses have been ruled out. Trouble is: essentially all current cardiac diagnostic tests are designed to identify big artery blockages, not dysfunction of the tiniest branches of the coronary arteries. There are some tests specifically for MVD, which I wrote about here. https://myheartsisters.org/2012/08/15/microvascular-and-spasm-disorders/ You could ask your cardiologist if these diagnostic tools could be useful for you if your own symptoms don’t continue to improve.

      Take care, stay safe. . . ♥


  3. That’s so true Sara – we are deeply conditioned to paste on that smile. When I was a little girl, for example, my Dad used to rattle off this little poem to his five children:

    “Don’t tell your friends about your indigestion –
    ‘How are you?’ is a GREETING, not a QUESTION!”

    Thus we learned very early on to just say “Fine!” – no matter what. I try to strike a balance between the fake “I’m fine!” smile and going on at length about every ache and pain! There’s a nice middle ground in there somewhere!

    Take care, stay safe. . . ♥


  4. I can’t do the forced smile thing anymore, though I’m sure I did it for decades.

    What I find is that with age, wisdom and meditation, I have become more balanced and accepting of circumstances, good and bad. I notice a small quiet smile creeping across my face at any given moment. Reflecting inner peace.

    This doesn’t come easily to these stressful times. But working towards equanimity and inner peace allows your face to reflect your truth.

    Forcing a smile causes an inner and outer incongruity that to me is like nails on a chalkboard.

    Sending Love & Peace to all Heart Sisters ❤️

    Liked by 1 person

    1. Thanks for this, Jill. I love the image of that “small quiet smile” – the polar opposite of a fake pasted-on smile because, like the “deep acting” described here by Dr. Scott, it actually does reflect genuine peace.

      I also find that snuggling my little grandbaby Zack brings on that small quiet smile (and even works for hours just by remembering those snuggles!)

      Take care, stay safe. . . ♥


    2. Thank you, Jill, for writing these words: “working towards equanimity and inner peace allows your face to reflect your truth.” I’m not good at expressing my real feelings as that always got me into trouble as a child. It’s especially bad with doctors as they are authority figures to me. I am slowly learning to let go of that toxic background. Being true to my inner self is important to healing – but I don’t know who my inner self is.

      As I’ve become sicker, though, I’ve gotten better at releasing the “I’m just fine and dandy” smile and expressing my genuine feelings of (sometimes) despair and (always) physical malaise.

      I’m not sure what good it does, as the doctors, specialists and family practice haven’t a clue how to help me. But it allows me to begin to be true to my inner self. I think that’s a good thing, but it’s scary.


      Liked by 1 person

  5. Yes, all of this. For those of us living with stage iv metastatic breast cancer, a terminal diagnosis, there is pressure to present that smile to the world, to act as if the dying while living thing is attainable and, dare I say, doable.

    I learned my lesson, though, my stage iv mets went undiagnosed for months because I didn’t complain about my limp. A 5 cm tumor in the middle of my right femur was the culprit. Now, my docs get it all whether they want it or not.

    Liked by 1 person

    1. Such an important point, Abigail! I know that if one of our children were limping, we’d be COMPLAINING loud and clear until we learned the cause. I suspect that feeling pressured to present that “smile to the world” – even with metastatic cancer – can be largely chalked up to the cutesy pinkification of Breast Cancer Awareness campaigns, and the misguided cheerleading that somehow suggests that if only women had the correct attitude and positive outlook, “You too can BEAT THIS!!!!” Sometimes, this is simply not true.

      Please take care, and stay safe out there. . . ♥

      Liked by 1 person

  6. It is so frustrating to hear people — including my PCP — tell me how well I look when I feel like a heavily mauled chew toy. Ischemic heart disease/coronary microvascular dysfunction don’t show up in my face even if I look serious and I’m not fake-smiling, so of course some people probably doubt that I have a problem. The solution? Ha! TBD.

    Liked by 1 person

    1. Hello Sandra – a “heavily mauled chew toy”? That’s quite the vivid description of MVD symptoms! Let me know when you find that solution. . .

      Take care, and stay safe… ♥


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