What becomes of the broken-hearted?

Most of us know or can at least imagine what broken-heartedness feels like. But what does it actually involve for the body? Cathy Holding gets to know her stress cardiomyopathy from her catecholamines

In the legend of the lovers Tristan and Isolde, Tristan lays dying of a mortal wound. The only thing keeping him from death is the hope that his beloved Isolde is coming to save him. Deceived into believing that she is not going to arrive after all, Tristan turns his face to the wall and dies in despair. When Isolde finally does arrive, she finds her lover already dead and, laying down beside him, she too dies with her lips against his and her arms around him. Dying of a broken heart is the stuff of legends and stories but can it really happen? According to Ralph Nickleby, Charles Dickens's uncle of Nicholas, " I can understand a man's dying of a broken neck, or suffering from a broken arm, or a broken head, or a broken leg, or a broken nose, but a broken heart! nonsense, it's the cant of the day." However, Mr Nickleby is wrong. People do die of a broken heart.

In the graveyard of St Margaret's Church Whitnash stands the tombstone of a 20-year-old virgin Catherine Bodenton, who died in 1725, that bears the inscription, "All you yt [that] come, my grave to see, Take warning here and learn by me, And let not true love break your heart, Or death will seas and you'll depart."

The deaths of lovers and partners is not the only cause of death by broken heart. The desperately sad story of Janette Hamilton, who died at the age of 41, never knowing what happened to her missing daughter Vicky, is a case in point. The similarly tragic death of the solicitor Sally Clark, wrongly accused of murdering her two sons (who actually died of cot death), was also described as being the result of a broken heart. My own grandmother died within months of the death of my father, which we attributed to her broken heart, and a friend of mine describes how her mother was killed in a car crash, and her father's health deteriorated soon afterwards until he died less than two years later. Death from a broken heart can also be inflicted on others by the bearer of the broken heart, or it can be self-inflicted. Media reports of such murders and murder-suicides seem uncomfortably frequent and all of them are tragic.

An idea of the scale of heartbreak in the UK in 2007 can be gathered from the fact that around 1.5 per cent of young people aged 20-24 years are separated and not co-habiting, and 0.8 per cent divorced, while 3 per cent per cent and 9.6 per cent of older people aged 45-49 years are respectively separated or divorced. Between 2006 and 2007, 144,220 divorces were granted in the UK. Almost 1,000 people a day lose a spouse through death. That's a lot of heartbroken people. What happens to them?

The scientific answer is this. In the first few months following bereavement, suicidal ideation (that is, thinking about suicide and attempted suicide) is most common in widows, and more common in widowers than among married people. A Swiss study found that, annually, 941 men and 207 women per 100,000 head of population committed suicide in the first week of bereavement. There is also stark evidence that many men react to romantic rejection by resorting to violence against the rejector: as many as 37 per cent of female murder victims are killed by their current or former intimate partner.

But there is more to it than that. What happens to our brains when romantic love is rejected? Brain imaging shows that rejected lovers have greater activity in the ventral striatum/putamen/pallidum than people who are happily in love. This area of the brain is also active in people who are undertaking high risk activities for big gains or for big losses in other words, risky gambling. The brain systems associated with reward and motivation those found to be active in people who are newly in love are still active in people who have recently been romantically rejected, but the activity is in a slightly different location.

Another region activated in the brain of rejected souls is the anterior insula/operculum cortex. Activity here has been found to be associated with skin and muscle pain and with anxiety in other words, love (or the rejection of it) does actually hurt. Yet another region involved is the lateral orbitofrontal cortex this is the area of the brain used by a person who is controlling emotional responses such as rage. The results coincide with what we normally see in a person who has recently been rejected and is going through the early stages of rejection ie. feeling pain and anger, and yet still trying to keep a lid on their emotions. Other studies have shown that people who experience prolonged and unabated grief (called complicated grief) cannot get over the loss of their loved one because the reward activity in the brain continues to be activated by reminders of the lost person. These results help explain why some people engage in obsessive/compulsive behaviours and spend hours thinking about the intentions and actions of the rejecting lover, and contemplating their own options. They might lead to explaining why in the extremes, rejection can make people suffer clinical depression, or resort to stalking, murder or committing suicide.

Most notably, however, is the recognition of a unique condition known as broken heart syndrome otherwise known as stress cardiomyopathy, takotsubo cardiomyopathy or left ventricular apical ballooning syndrome. It is brought on by sudden emotional stress and results in heart failure and transient systolic dysfunction of the left ventricle of the heart. It manifests as severe chest pain, difficulty in breathing and low blood pressure, and was for years mistaken by physicians as acute myocardial infarction or a heart attack but there is usually no evidence of previous obstructive coronary artery disease. Catecholamines hormones released during sudden extreme stress are thought to be behind the effects on the heart muscle. It is estimated that 1-2 per cent of people believed to be having a heart attack are actually experiencing this syndrome. Reports in the scientific literature of the condition have increased over the last five years, and it occurs most frequently in post-menopausal women. Prognosis is usually good but people have died of a broken heart.