Psychology
2011. Vol.2, No.4, 382-387
Copyright © 2011 SciRes.

DOI:10.4236/psych.2011.24060

Romantic Breakups, Heartbreak and Bereavement*—Romantic Breakups
1

Tiffany Field1,2
Touch Research Institute, School of Medicine, University of Miami, Miami, USA;
2
Fielding Graduate University, Santa Barbara, USA.
Email: tfield@med.miami.edu
Received March 26th, 2011; revised May 11th, 2011; accepted May 20th, 2011.

This literature review suggests that romantic breakups may lead to bereavement symptoms including intrusive
thoughts and attempts to suppress them and insomnia as well as morbidity factors including broken heart syndrome and immune dysfunction. Although the broken heart syndrome has mimicked real heart attacks, angiograms revealed no clogged arteries or permanent heart damage. Compromised immune function may result
from reduced vagal activity and increased cortisol and catecholamines leading to increased inflammatory cytokines and decreased natural killer cell activity. The model proposed here is that romantic breakups result in theloss of a person as a regulator of stimulation and arousal modulation that can then lead to these physiologicaland biochemical effects. These data highlight the complexity of romantic breakups, heartbreak and bereavement
and the need for multi-variable research on these systems both before and after the breakups occur.
Keywords: Romantic Breakups, Heartbreak, Bereavement, Social Regulators

Romantic breakups can be followed by symptoms of heartbreak and bereavement (Prigerson & Jacobs, 2001; Raphael,
Minkov, & Dobson, 2001; Davis, Shaver, & Vernon, 2003),
typically, these symptoms have been associated with a loss
from death, although they can also occur following other losses
like divorce and romantic breakups (Prigerson & Jacobs, 2001;
Davis et al., 2003).
This review of research from these different literatures suggests that romantic breakups, like the losses following death or
divorce, can lead to bereavement symptoms including intrusive
thoughts, difficulty controlling intrusive thoughts and insomnia
as well as heartbreak syndrome and compromised immune
function. Studies on bereavement symptoms, heartbreak syndrome and immune dysfunction are followed by a summary of
research on romantic breakups and their symptoms. A potential
underlying mechanism model is then presented, suggesting that
it is the loss of the person as a regulator of stimulation andarousal modulation that can result in physiological and biochemical dysregulation including reduced vagal activity, increased cortisol and catecholamines and compromised immune
function. Limitations of this literature are then suggested aswell as future research including multi-variable studies that
could assess these systems both before and after the breakups
occur.

Bereavement Symptoms
Bereavement symptoms have varied cross-culturally, withmore symptoms reported for non-Western cultures (Kleinman*

This research was supported by a merit Award (MH46586), NIH grants(AT00370 and HD056036) and Senior Research Scientist Awards (MH0033
and AT0011585) and a March of Dimes Grant (12-FY03-48) to Tiffany
Field and funding from Johnson and Johnson Pediatric Institute to the Touch
Research Institute.

& Good, 1985), and the symptoms have differed even within
religions. For example, Egyptian Muslims show intense grief,
while Muslims in Bali do not (Wikan, 1988). Contradictorydata include an international study that reported very similar
symptoms across diverse cultures (Simon, VonKorff, Piccinelli,
Fullerton, & Ormei, 1999). In that large sample study, sleep
disturbances were among the most frequently reported symptoms across cultures (Simon et al., 1999).

Sleep Disturbances
Sleep disturbances have been reported by as many as 43% of
bereaved subjects in one sample (Bisconti, Bergeman, & Boker,
2004), and poor sleep has been noted in bereavement-related
depression (McDermott, Prigerson, Reynolds, Houck, Dew,
Hall et al., 1997; Hardison, Neimeyer, & Lichstein, 2005). In a
study on college students, for example, insomnia was greater inbereaved versus non-bereaved groups (22% versus 17%) (Hardison et al., 2005), with sleep onset insomnia being related tonighttime ruminations about the loss, and sleep maintenanceinsomnia being related to dreaming about the lost person. Elevated cortisol has also contributed to poor sleep including more
REM sleep and less delta wave activity (Reynolds, Hoch,
Buysse, Houck, Schlernitzauer, Pasternak et al., 1992), although it is not clear whether those EEG sleep changes preceded or followed the depression.

Intrusive Thoughts and Attempts to Control Intrusive
Thoughts
Intrusive images and attempts to control them are thought tocontribute to the insomnia associated with bereavement. Insomnia, based on actigraphic recordings, for example, has resulted from unpleasant images (Nelson & Harvey, 2002). And,
unpleasant images have been correlated with sleep onset la-

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tency, with more of those images related to intimate relationships. Pre-sleep images have also been rated as less controllable
than pre-sleep verbal thoughts, although more disengagement
has been noted from images than verbal thoughts (Nelson &Harvey, 2003). Negative images have also been associated withhigher heart rate, which is surprising given that negative verbal
thoughts typically elicit greater cardiovascular responses thannegative verbal images (Vrana, Cuthbert, & Lang, 1986).
Attempts to suppress the images and thoughts often lead todreams. In one study, participants were asked to think about aromantic “crush” or a “non-crush” (Wegner, Wenzlaff, & Kozak, 2004). Although there was no greater dreaming about theromantic “crush,” suppression enhanced eroticism of the“crush”. Thus, the increased accessibility of intrusive thoughts
resulting from thought suppression transferred even to dreams.

Potential Morbidity Factors
Morbidity factors have also been associated with bereavement. And, romantic breakups may be a risk factor for the more
serious complications associated with bereavement including
broken heart syndrome (Wittstein, Thiemann, Lima, Baughman,
Schulman, Gerstenblith et al., 2005) and endocrine and immune
dysfunction (Frazier, Strauss, & Steinhauer, 2004).

“Broken Heart” Syndrome
The “broken heart” or heartbreak syndrome has been described as physical pain in the heart or chest after losing someone. Although the heartache mimics symptoms of a real heart
attack, those with broken heart syndrome typically recoverfaster (Wittstein et al., 2005). This condition has also beencalled stress cardiomyopathy or “takotsubo cardiomyopathy,”
takotsubo being a fishing pot with a narrow neck and a widebase that is used to trap octopus in Japan, a shape that is similar
to that of the left ventricle. Cardiac contractile abnormalities
and heart failure have been recorded by several investigators,
although angiograms have revealed no clogged arteries inheartbreak, unlike real heart attacks (Kawai, Suzuki, Yamaguchi et al., 2000; Kurisu, Sato, Kawagoe, Masaharu, Yuji, Kenjiet al., 2002; Villareal, Achari, Wilansky, & Wilson, 2001).
Norepinephrine and epinephrine levels have also been elevated (7 - 34 times the normal levels) in individuals with broken heart syndrome, but cardiac enzymes typically released
from damaged heart muscle during real heart attacks were notnoted (Wittstein et al., 2005). Echocardiograms suggested that
although the left ventricle was contracting normally, there appeared to be a weakened contraction in the middle and upper
portions of the heart muscle, and inverted T waves and prolonged Q-T intervals which are often associated with stresswere noted. Magnetic resonance imaging scans suggested thatnone of the broken heart syndrome patients suffered irreversible
heart damage, and their recovery rates were faster (typicallytwo months) than after real heart attacks (Akashi, Nakazawa,
Sakakibara, Miyake, Koike, & Sasaka, 2003; Nyui, Yamanaka,
Nakayama, Sawano, & Kawai, 2000).
Potential underlying mechanisms offered for these effects include: 1) increased catecholamines causing spasms in the coronary arteries (Wittstein et al., 2005); 2) multiple simultaneous
spasms of the coronary arteries that would cause enough loss ofblood flow to lead to the transient stunning of the heart (Kurisu

383

et al., 2002); and 3) a failure of the arteries to provide adequate
oxygen to the heart (Kawai et al., 2000). Most of these researchers have suggested, however, that all of these factors may
be operating.
Unfortunately, many of these studies were based on small
samples, and although there are strong associations between
increased heart rate and the release of catecholamines and theresultant cardiomyopathy, the relationships are only suggestive.
The elevated catecholamines may simply be an epiphenomenon
or a secondary response in the patients with the stress cardiomyopathy rather than an original cause. Nonetheless, elevatedcatechalomines are typically indicative of elevated stress andwhen prolonged can lead to endocrine and immune dysfunction.

Endocrine and Immune Dysfunction
Decreased vagal activity and increased skin conductancehave been associated with elevated stress (Frazier et al., 2004),
and increased heart rate and blood pressure have been accompanied by increased cortisol and norepinephrine levels, which
when prolonged can have negative effects on the immune system (Uchino, Kiecolt-Glaser, & Glaser, 2000). This initial“fight-or-flight” mechanism is adaptive in mobilizing energy
stores leading to increased inflammatory cytokines which ultimately mobilize antibodies as a defense against infection(Black, 2002). In this way, immune activity is initially enhanced, but, over time, elevated stress hormones and cytokine
activity can result in impaired immune function (Kiecolt-Glaser,
McGuire, Robles, & Glaser, 2002). Compromised immune
function occurs via the necrotic effects of stress hormones on
the immune organs. Examples have been given of elevatedinflammatory cytokines (IL-1, IL-2, IL-6 and PNF-alpha) accompanying the depressed state (Leonard, 2006), as well as
higher antibody titres to the Epstein-Barr virus and lower thannormal natural killer cell activity (noted to kill bacterial, viraland cancer cells) following divorce (Powell, Lovallo, Matthews,
Meyer, Midgley, Baum et al., 2002).
Bereaved individuals have had profiles of high anxiety anddepression scores, elevated cortisol and decreased natural killer
cell activity which in some individuals lasted for as long as six
months (Gerra, Monti, Panerai, Sacerdote, Anderlini, &Avanzini, 2003). These physiological and biochemical changes
may contribute to the greater incidence of physical illnesses(following “betrayal”) (Freyd, Klest, & Allard, 2005) and heartdisease (related to “broken hearts”) (Johnson & Grippo, 2006)
in bereaved individuals.

Romantic Breakups
Although most adults are resilient following romantic
breakups, some experience symptoms similar to those of bereavement including intrusive thoughts, insomnia and depression. In a study conducted by our group, university students
who experienced romantic breakups had elevated scores on
intrusive thoughts, difficulty controlling intrusive thoughts andinsomnia scales (Field, Diego, Pelaez, Deeds, & Delgado, 2009)(see Table 1). In a regression on these data, scores on thesescales contributed to 34% of the variance on breakup distresswhich was experienced by 58% of the students following romantic breakups (see Table 2).
Similarly, in a survey of more than 5000 internet respon-

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384

Table 1.
Means for high and low Breakup Distress Scale scores groups (Standard deviations in parentheses).
Primary Variables

Low

High

F

p

Intrusive Thoughts

2.88 (2.94)

5.63 (2.84)

15.27

.000

Controlling Int. Thoughts

15.73 (10.61)

26.05 (8.18)

27.20

.000

Sleep Disturbances

4.00 (2.39)

5.35 (2.97)

9.07

.003

Depression (CES-D)

13.56 (9.30)

20.88 (11.22)

8.15

.005

Anxiety (STAI)

38.36 (11.34)

45.69 (10.55)

9.05

.003

Table 2.
Stepwise regression on breakup distress.
StepR

R squareR2 change

F for change

P

1

.46

.21

.21

57.19

.000

2

.56

.32

.11

34.06

.000

3

.58

.34

.02

7.33

.007

Predictors in order of their entry, 1) Sleep disturbance scale; 2) Intrusive thoughts
scale; 3) Controlling intrusive thoughts scale.

dents, romantic breakups were associated with more extreme
physical and emotional distress including exaggerated attempts
to re-establish the relationship, angry and vengeful behavior,drugs and alcohol use (Taylor & Bryant, 2007). Laboratory
studies have also been conducted to assess physiological andbiochemical changes associated with bereavement and romantic
breakups including regional brain and neurotransmitter activity.

Regional Brain Activity
Bereavement and romantic breakups have been assessed forregional brain activity by positron emission tomography (PET)and functional magnetic resonance imaging (fMRI). In a paper
entitled “Craving love? Enduring grief activates brain reward
center”, PET showed reduced cerebral blood flow to the hippocampus in individuals with bereavement symptoms (O’Connor,
Wellisch, Stanton, Eisenberger, Irwin, & Lieberman, 2008).
The more severe the symptoms, the less blood flow to this region. In contrast, increased blood flow has been noted for the
cingulate cortex in fMRI studies. This was shown in bereaved
women, for example, in a paradigm in which grief was elicitedby photographs of the lost person (Gündel, O’Connor, Littrell,Fort, & Lane, 2003), and in women who were grieving the lossof a romantic relationship (Najib, Lorberbaum, Kose, Bohning,& George, 2004). Involvement of the cingulate cortex is consistent with brain activity associated with rejection and themixed emotional state of sadness, anger and anxiety, suggestingthat rejection may be a key factor in romantic breakups (Eisenberger, Lieberman, & Williams, 2003).

fMRIs of Rejected Love are Similar to Those of
Romantic Love
Paradoxically, the same brain areas that light up in those experiencing romantic breakups also light up in individuals in
long-term love relationships. In a recent study, women who
were still very much in love but had been rejected by their ro-

mantic partner alternately viewed a photograph of their abandoning loved one and a photograph of a familiar individual(Fisher, Aron, & Brown, 2006). These researchers then compared their data on rejected lovers with the results from a study
on happily-in-love individuals (Aron, Fisher, Mashek, Strong,
Li, & Brown, 2005).The data showed that activity in regions
associated with physical pain increased during both love andrejection.
The PET and fMRI data are difficult to interpret, and it is notclear that they would lead to any implications for treatment,
especially since similar areas appear to be activated both during
romantic relationships and after romantic breakups. However,these findings are noteworthy inasmuch as they are consistent
with data showing that biochemical profiles are also similar forboth romantic love and romantic rejection.

Romantic Breakups and Romantic Love Also Have
Similar Biochemical Profiles
The brain also releases similar chemicals for both romantic
breakups and romantic love including pheromones, dopamine,
norepinephrine, epinephrine and serotonin. As dopamine andnorepinephrine levels increased, serotonin levels decreased, andthese changes were associated with increased heartrate, trembling, flushing, pupil dilation, sleeplessness and loss of appetite(Fisher, 2006). These data are understandable given that these
physiological and biochemical responses have generally been
noted during stressful situations (Luciana, Collins, & Depue,
1998; Griffin & Taylor, 1995).

Potential Mechanisms Underlying Romantic
Breakups, Heartbreak and Bereavement
Potential underlying mechanisms have been explored forromantic breakups, heartbreak and bereavement. These include
loss of regulation models labeled “relationships as social regulators” and “psychobiological attunement”.

Relationships as Social Regulators
In the social regulators model of bereavement, the loss of asignificant other represents the loss of major social time cues((Ehlers, Frank, & Kupfer, 1988). In seminal papers on “Relationships as Regulators”, Hofer outlined a model for the loss ofa relationship as being the loss of a regulator (Hofer, 1984,1996). He suggested that losing an attachment figure means“losing regulatory control of stable daily patterns, of tasks,
attention, concentration, sleep, food intake and mood, such thatthey become fragmented, and the individual has a sense of in-

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ternal disorganization”.
Relationships can help maintain psychological and physiological equilibrium, as each person is associated with a state of
psychological security and physiological calm for the other andserves to up- or down-regulate the partner’s psychophysiological arousal (Hofer, 1984, 1996; Depue & Morrone-Strupinsky,
2005; Sbarra & Hazan, 2009). This co-regulation is considered
a property of the relationship (not a property of either individual alone), and, it can occur through several senses (e.g. touch,smell, eye contact) and is thought to regulate and synchronize
body rhythms. In the absence of the “co-regulator,” the psychological and physiological rhythms can become dysregulated,leading to dysphoria, restlessness/agitation, sleep disturbances,changes in appetite and decreased vagal tone (Sbarra & Hazan,2008).
Dysregulation can happen when a partner is absent, for example, during business trips and military deployments, as sleep
disturbances have been noted during the travel period, and theindividuals then return to a regulated state following reunion(Diamond, Hicks, & Otter-Henderson, 2008). It can also happen during threat conditions that can be alleviated by holding
the hand of one’s partner versus the hand of a stranger (Coan,Schaefer, & Davidson, 2006). The authors of the handholding
study suggested that the threatened person “borrowed emotional and physiological stability from the partner”. Some havenoted that even mental representations of one’s partner can bedysregulating following a breakup or loss, leading to intrusive
thoughts and disturbing dreams (Uvnäs-Moberg, 1998).
Most of the examples given have involved the partner decreasing arousal levels rather than helping find a balance between under- and over-arousal. Under-arousal could be equally
disturbing as, for example, the sensory deprivation experienced
by individuals who are in military combat and confined to lightand sound-proof chambers (Hofer, 1984).

Loss of Psychobiological Attunement
A model called “psychobiological attunement” or “being on
the same wavelength”, accommodates both the need for optimal
stimulation and for arousal modulation (Field, 1985, 1996). In
this model, each partner provides meaningful stimulation forthe other and has a modulating influence on the other’s arousal
level. Both over-stimulation and under-stimulation are aversive,and stimulation that brings or keeps an individual within an
optimal arousal zone is considered reinforcing. Thus, the loss ofa significant other means the loss of both activating and calming stimulation. The individual experiencing the loss would be
expected to fluctuate between one end of the continuum of
under-stimulation and the other end of over-stimulation and not
be able to modulate these levels to experience optimal arousal
levels.
Other terms used to describe this phenomenon were synchrony and sharing rhythms (Field, 1985, 1996). Synchrony is aterm that is usually applied to the matching of physiological or
physical activity rhythms by individuals in a close relationship.
Examples of this can be seen in partners who are extremely
close tending to coordinate their physical movements and expressions while talking, as well as their cortisol cycles tending
to be synchronized on weekends when they are together (Field,
1985, 1996). Thus, attunement or “being on the same wavelength” happens for both behavioral and physiological rhythms

385

in adults who have a close relationship. Seemingly, the only
way this could happen is if each partner of the dyad is sensitiveand responsive to each other’s stimulation and arousal-modulation needs, as in a feedback loop, and each accordingly adjusts his or her behavior to facilitate the behavioral and physiological synchrony of the couple.
If and when the partner is not there to meet the needs for different types and degrees of stimulation, dysregulation may
occur including physiological disorganization such as decreased
vagal activity (Frazier et al., 2004; Diego, Field, & Hernandez-Reif, 2007), and in some cases changes in immune function
such as increased inflammatory cytokines (Leonard, 2006) anddecreased natural killer cell activity (Powell et al., 2002). In ourmodel, the loss of a loved one may result in this dysregulation
simply because the source of stimulation and arousal modulation is no longer present (Field, 1985, 1996).
Physical intimacy can enhance attunement (Fisher, 2004).
Via touching, individuals can learn each other’s stimulation andarousal modulation needs. Although it is possible to self-regulate in the absence of an intimate partner, it may not be as easy
or effective. When a partner is no longer there and touch
stimulation, for example, is missing, it may become necessary
to find that type of stimulation from other activities until a newpartner is found. Massage, yoga, and other forms of exercise,for example, may help avoid the physiological dysregulationand immune problems that can result from touch deprivation(Field, 2009).

Limitations of This Research and Future
Directions
The intent of this review was to summarize the limited literature on romantic breakup symptoms that are similar to thoseof the bereavement syndrome including intrusive thoughts,
attempting to control intrusive thoughts and insomnia and more
serious complications including heartbreak syndrome and immune dysfunction. Much of the discussion regarding romantic
breakups, however, is mere speculation based on the bereavement and heartbreak syndrome literature. And, the bereavement
and heartbreak syndrome literature has the problem that thedata are derived primarily from loss related to death and divorce. These likely have commonalities with romantic breakups,
but also major differences, as in divorce not only involving
betrayal and rejection but also having to continue the relationship for family reasons and death involving a permanent loss.
Even within the loss by divorce and the loss by death literatures,comparisons across studies are problematic given the different
measures, the different intervals from the time of loss to thetime of assessment, and the different age, ethnic and culturalgroups assessed (among other potentially confounding variables).
Other nuisance factors are the small sample sizes and themeasurement of only one or two variables. This is particularly
problematic when the results appear paradoxical such as thefMRI data showing that the same region of the brain is activated by romantic breakup and by romantic love and the same
biochemical profile emerging (albeit from different studies).
Without converging variables such as behavioral data, thesefindings are difficult to interpret. And, as already mentioned,
they are not perhaps useful for informing potential treatment

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386

options. In brief, in any of these research areas, multi-variable
studies would be more informative. Combining self-report,
behavioral, physiological and biochemical measures in thesame sample of individuals experiencing loss from the samecause would be optimal.
Perhaps the greatest weakness of these literatures is that it is
not clear what is happening in relationships that are then missing when the loss occurs, whether by death, divorce or romantic
breakups. Reviewing the “social regulators” and the “psychobiological attunement” models in this paper was meant to highlight how little we know about what changes occur from before
to after the loss or what was critical about the relationship thatwas then missing after the loss occurred. This, of course, isalways difficult given the longitudinal nature of the problem.
However, convenience samples could be researched such asuniversity students whose relationships tend to be short-lived,
affording the opportunity to collect behavioral, physiologicaland biochemical data during the relationship and after the
breakups. To address these questions, we are currently designing research to videotape interactions of university student couples during their relationships and after their break-ups as well
as recording their heartrate and assaying saliva samples forcortisol levels. Relationships between older couples, for example couples in assisted living, could also provide the opportunity for studies of long-term relationships that are “snuffed out”
by the death of one partner. These are potential challenges forthe very important problem of determining how to alleviate thesignificant social pain of loss, be it by death, divorce or romantic breakups. In a sense, each of these, no matter the cause, areromantic breakups that can be chronically painful and therapeutically costly.

Summary
In summary, romantic breakups, heartbreak syndrome andbereavement are complex behavioral, physiological and biochemical phenomena. Romantic breakups may be at risk for thesymptom profile of bereavement including intrusive thoughts
and attempts to suppress them as well as insomnia and more
serious complications including broken heart syndrome andimmune dysfunction. Although the broken heart syndrome
mimics a real heart attack, it has been differentiated from heart
attacks by angiograms revealing unclogged arteries and nopermanent heart damage. Reduced vagal activity and increased
cortisol and catecholamines are thought to lead to the associated immune dysfunction including increased inflammatory
cytokines and reduced natural killer cell activity. Potential underlying mechanisms for romantic breakups, heartbreak andbereavement effects include the loss of social regulators who
provide optimal stimulation and arousal modulation. These data
highlight the complexity of romantic breakups, heartbreak andbereavement and the need for further multi-variable researchthat is conducted both before and after the breakups.

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