Romantic Breakup Distress, Betrayal and Heartbreak: A Review

A review of the romantic breakup distress, betrayal, and heartbreak.

The breakup distress that occurs can be explained in part by depression and feelings of rejection and betrayal. These may lead to physical problems including heartbreak or the broken heart syndrome and immune dysfunction.

The broken heart syndrome has notably mimicked heart attacks, but it has been differentiated from a real heart attack by angiograms revealing unclogged arteries and no permanent heart damage.

Reduced vagal activity and increased cortisol and catecholamine levels (dopamine and norepinephrine) accompanying heartbreak are thought to be potential underlying mechanisms for the broken heart syndrome and for immune dysfunction including increased inflammatory cytokines and reduced natural killer cells.

fMRIs following breakups have revealed increased activity in the cingulate cortex and the right ventricular prefrontal cortex. These data highlight the complexity of breakup distress, betrayal and heartbreak and the need for multi-variable research.

This narrative review involved a literature search on the terms romantic breakup distress, betrayal and heartbreak on PubMed and PsycInfo.

For the selection process, the inclusion criteria were: published empirical studies, systematic reviews, and meta-analyses. Exclusion criteria included: non-English papers, case studies, underpowered samples, and non-juried papers.

Following these screening criteria, But what does the review say about breakup distress?.

Romantic Breakup Distress

Although romantic breakups, breakup distress and heartbreak are common among adults, and most of the studies on these topics have been conducted with university students, as reflected by the literature reviewed in this paper.

Romantic breakups occur in as many as two-thirds of university samples. The breakups frequently lead to breakup distress which is often associated with depression, feelings of rejection and betrayal, heartbreak symptoms including chest pain and compromised immune function. This review summarizes some of that literature.


In a phone survey, romantic breakups were one of the most commonly reported “worst events” and they were a significant risk factor for depression. In another study, over 40% of those experiencing romantic breakups became clinically depressed (12% experienced moderate to severe depression).

Women typically experience more severe depression and hopelessness following breakups, being twice as likely to be depressed as men. However, men are three to four times more likely to commit suicide after romantic breakups.

Depression, in turn, has been related to loneliness (an incidence of 35% for female university students and 24% for male students), and, here again, women had higher depression and loneliness scores. Heart attacks and strokes can also follow breakups and depression.



Feelings of betrayal often accompany feelings of rejection, and betrayal also entered the regression analysis on breakup distress in the Field et al., (2009) study.

Betrayal has been defined as “…a sense of being harmed by the intentional actions or omissions of a person who was assumed to be a trusted and loyal friend, relative, partner, colleague or companion. Many betrayals are unexpected events that come as a surprising shock; not infrequently, the betrayal is disbelieved at first. The effects of a betrayal tend to be long-lasting, even permanent, and are well-remembered” .

Some symptoms of betrayal are distress, intrusive images, and rumination. Others have studied betrayal as the loss of “social provisions”, most especially the loss of attachment to and guidance from the betrayal partner. In this study, 91% of the participants lost social provisions from their partners following romantic betrayal.

In a study on university students, the level of betrayal was assessed by the closeness of the relationship. Those with a high betrayal that happened in close relationships had more symptoms of depression and PTSD.

In another study, betrayal was measured by three scales including 1) The Brief Betrayal Trauma Scale that defines high levels of betrayal as occurring in a close relationship and low levels in a non-close relationship; 2) The Impact of Event Scale  that assesses symptoms of intrusion, avoidance, and hyperarousal; and 3) the Trauma Symptom Checklist  that assesses symptoms related to depression, anxiety, sleep disturbance, dissociation and sexual problems.


Physical pain in the heart or chest after losing someone has been labeled heartbreak or the broken heart syndrome. This acute pain has also been called stress cardiomyopathy or “takotsubo cardiomyopathy”. Takotsubo is a fishing pot with a narrow neck and a wide base that is used to trap octopus in Japan, and the left ventricle of the heart looks like that fishing pot following heartbreak.

Heartbreak has led to endocrine and immune dysfunction and serious medical conditions including cancer, hypertension and heart attacks. Although the heartache mimics symptoms of a heart attack, those with broken heart syndrome typically recover faster.

Cardiac contractile abnormalities and heart failure have been recorded by several investigators following acute emotional stress. Angiograms, however, revealed no clogged arteries in heartbreak, unlike real heart attacks.

In addition, cardiac enzymes typically released from damaged heart muscle during real heart attacks have not been reported. Although other heart changes associated with stress also occur including weakened contractions in the left middle and upper portions of the heart muscle and inverted T waves.

These heart changes have been attributed to exaggerated sympathetic stimulation and elevated catecholamines including norepinephrine and epinephrine.

Social Pain And Physical Pain Activate Similar Brain Regions

The same region (the right ventral prefrontal cortex) has been active in neuroimaging studies during painful stimulation. Greater RVPFC activation was associated with less pain. Because the RVPC is involved in cognitive activities, its activation during pain suggests the therapeutic use of cognitive tasks to interrupt social pain.

Cognitive tasks have been successful at least in reducing the impact of intrusive thoughts following rejection and loss. Thus, the underlying mechanisms common to physical and social pain include the location of the brain (the anterior cingulate cortex and the right ventral prefrontal cortex) and the opioid system.

Many of the neuroimaging studies that suggested that social rejection activated the pain matrix were Cyberball studies and small sample studies. A meta-analysis of the Cyberball studies, however, failed to support the claim that social and physical pain activate the same regions.

And, in a study in which participants experienced both physical pain (heat) and social pain (photos of ex-partners) on separate trials, the fMRI patterns discriminated the physical and social pain conditions, i.e. those conditions did not activate the same region (the anterior cingulate cortex).

fMRIs Of Rejected Love Are Similar To Those Of Romantic Love

The same brain areas that light up in long-term love relationships also light up in rejected relationships. In this study, women who were still in love with their rejecting partner viewed a photograph of their rejecting loved one and a photograph of a familiar individual interspersed with a counting task.

Similar brain areas were activated for rejected lovers, although they showed greater activity in the ventral pallidum than the in-love sample. This region has been associated with uncertain reward and delayed reinforcement. These data suggest that the brain systems involved in reward and motivation remain active in those who have been romantically rejected.

The data also showed that activity in regions associated with physical pain increased during rejection. These findings are consistent with data showing similar biochemical profiles for romantic love and romantic rejection.

Protective Factors

Several protective factors have been discussed in the literature on break-up distress including personality characteristics such as self-esteem, attachment style (secure versus anxious attachment), coping style, and rejection sensitivity. Other factors such as forgiveness, finding a new partner/ rebound, social support, healthy diet, heartbreak songs, and ball sports and dancing can mediate breakup distress. Finally, interventions, including cognitive behavioral therapy, intranasal oxytocin, and MDMA (3-4-Methylenedioxymethamphetamine) have been effective.

This study first published in International Journal of Behavioral Research & Psychology  by SciDoc Publishers.



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