Motivation and emotion/Book/2018/Broken-heart syndrome

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Broken-heart syndrome:
What is BHS, how does a break-up cause it, and what can be done about it?

Overview[edit]

Figure 1. Left ventricular diagram

Takotsubo Cardiomyopathy (Broken-Heart Syndrome/ Stress-Induced Syndrome) is a temporary heart condition that is brought on by stress. The term Tako-Tsubo represents an octopus pot that Japanese fishermen used in order to catch octopuses. As it physically resembles the left ventricle of the heart, this heart condition was coined with the term Takotsubo Cardiomyopathy. It was discovered in Japan and first described in the 1990s. Emotional trauma and psychological stressors can trigger this syndrome by disrupting the heart's normal functioning, due to a surge of stress hormones. Examples of specific stressors may include:

  • Financial loss
  • Bad news
  • Domestic violence
  • Intense fear
  • Shock

The disorder has the same symptoms as a heart attack, but is not caused by any underlying cardiovascular disease (Gerhard Whitword,2017). It is a temporary heart condition that may also be caused due to physical illness and/or surgery. BHS has many different symptoms, such as, chest pain and shortness of breath, as well as more serious ones, such as movement abnormalities and ballooning in the left ventricle. The pathophysiology of BHS is not yet fully understood, however catecholamines are presumed to play a crucial role (Lyon et al., 2015). The biochemical changes associated with catecholamines have been demonstrated to affect heart rate and other physical responses typical for stressful situations (Field, 2011). There are also some heart mechanisms which may attribute to the cause of BHS, such as transient vasospasms, microvascular dysfunction and appical stunning (Kurisu et al., 2002), however their contributions are still not investigated. Furthermore, mental health problems have been associated with higher susceptibility for the occurrence of BHS, and vice versa, prolonged effects of BHS may result in onset of mental health disorders, such as anxiety and depression. Even though hospital data demonstrates that there is a high mortality rate among patients with BHS, an optimal treatment method has not been determined. For the time being, pharmacological treatment to restore normal functioning of the left ventricle is the most widely used option. Understanding concisely whether psychological effects are a precursor for BHS, or if BHS leads to psychological dysfunctions can potentially contribute to developing a single appropriate treatment, which integrates the work of psychologists and psychiatrists with cardiac physicians.

What is Broken-Heart Syndrome?[edit]

Broken- Heart Syndrome or Stress- Induced Syndrome is a temporary disruption of the heart's normal pumping function in one area of the heart, usually the left ventricle (Broken heart syndrome - Symptoms and causes, 2012). What's interesting is that the other areas of the heart remain unaffected, pumping at a normal rate or even producing more forceful contractions.

Broken- heart syndrome is simply caused due to the heart's muscle reaction after a surge of stress hormones like cortisol [[1]]. BHS Syndrome can be triggered not just by a break up, but also by the loss of a loved one, traumatic events, accidents, physical injury or even loneliness. So how common is this syndrome?

Figure 2. A broken heart

According to the American Heart Organisation, BHS is quite common, and as you may expect, an individual experiences this syndrome at least once in their lifetime. In a study from January 2005 to October 2010, only 256 cases of stress cardiomyopathy or BHS were reported across Europe and North America, which shows that not many people report BHS. In 2007, around 12000 Americans reported having this syndrome (Derrick, 2009).

The symptoms of broken-heart syndrome and a heart attack may overlap, however there are some differences. One experiences broken- heart syndrome after immediate emotional or physical stress. The American Heart Organisation has mentioned a few of them below:

  • EKG results for a heart attack and BHS are different;
  • For BHS, blood tests show no sign of heart damage;
  • There are no blockages in the coronary arteries in BHS;
  • For BHS, tests show ballooning in the left ventricle;
  • Recovery time for BHS is quick, usually takes weeks or in some cases days.

Pathophysiology of BHS[edit]

The pathophysiology of broken-heart syndrome is not yet fully understood, however catechaloamines [[2]] play a central role in the pathophysiology, as the trigger is a sudden unexpected stress (Lyon et al., 2015). This shows that in BHS there are signs of sympathetic activation at presentation and secondary medical triggers lead to extreme sympathetic activation (Lyon et al., 2015). Catecholamines are hormones that are produced by the adrenal gland. Dopamine, epinephrine and norepinephrine are the main types of catecholamines involved (Lyon et al., 2015). There are two main important physiological process to consider. The first being the cognitive centers of the brain and hypyothalamic- pituitary- adrenal axis, and second being the response of the cardiovascular system and the sympathetic nervous system to the sudden sympathetic activation and surge in circulating catecholamines (Lyon et al., 2015). They also suggested that catecholamine levels at presentation are relatively higher than the resting level in the same patient or in comparable patients who have acute heart failure caused by acute myocardial infarction. This suggests that there is potential for excessive hypothalamic–pituitary–adrenal gain and epinephrine release. Lyon et al. (2015) mentioned different hypothesis that explain the unique cardiac appearance in broken- heart syndrome, and the cardiac response to chronic stress. They divided the hypothesis into vascular and myocardial cause which may not be mutually exclusive, as the entire cardiovascular system is exposed to the same catecholamic release. These hypotheses are still being researched today, as there is no proven logical mechanism for broken- heart syndrome. There is however a possibility that the cause is likely a combination of more factors, even though there are studies that have showed conflicting results (Lyon et al., 2015).

Genetic Susceptibility Theory says that there is a strong environmental component in the pathophysiology of broken- heart syndrome. It is possible that some people may have a genetic predisposition (Lyon et al., 2015). Lyon et al (2015) stated that although the syndrome is not considered primarily genetic, there are many studies that have researched the possibility of genetics in cardiomyopathy. Nonetheless, the concept of a genetic predisposition has been recommended based on few broken- heart syndrome cases that have been described (Lyon et al., 2015). Contradicting results have been published regarding the presence or absence of functional poly-morphisms in relevant candidate genes, such as GRK5, and oestrogen receptors (Lyon et al., 2015). These studies had a very small number of participants. Resolving these conflicts will require high-quality phenotyping, identification of appropriate candidate genes, and sharing high-quality data within the BHS network (Lyon et al., 2015).

How does emotional trauma affect your heart?[edit]

[Provide more detail]

Emotional stressors[edit]

Figure 3. Fear

Psychological stressors have a range of traumatic emotions associated with them, and include grief (e.g:death of a loved one), personal conflicts (divorce or family issues), fear and panic (e.g: assault, public speaking or robbery), anger (e.g: argument with family or friends), anxiety and more. Psychological stressors may include financial problems or unemployment, embarrassment (e.g:defeat in a competition or legal proceeding) and natural disasters (e.g: earthquake). Emotional stressors may not only be due to negative events, but can be due to positive events too, such as a surprise birthday party, winning the lottery or a positive job interview. This is also known as happy heart syndrome (Ghadri et al., 2018).

Overdose of the serotonin–norepinephrine reuptake[edit]

Christoph et al. (2010) described a case study in which a 43 year-old woman was admitted to hospital for broken -heart syndrome, after an overdose of the serotonin-norepinephrine reuptake inhibitor Venlafaxine. The patient had accidentally taken 300mg of Venlafaxine instead of the prescribed 75mg. This overdose led to an increase of catechaloamine levels. Several antidepressants like tricylic antidepressants, selective serotonin reuptake inhibitors or monoamine oxidase inhibitors have a relevant influence on plasma catechaloamine levels (Christoph et.,2010). Golden and Nicholas, (2000) confirmed that the new generation of antidepressants, serotonin–norepinephrine reuptake inhibitors, increased the plasma catechohalomine levels, and this occurred because of the inhibition of the norepinephrine reuptake. This drug is said to have a highly efficient antidepressant that has good tolerability, and Venlafaxine is said to be a very safe drug with rare cardiovascular adverse effects (Christoph et al., 2010). In 2007, Venlafaxine was the sixth most commonly described antidepressant with over 17.2 million prescriptions.

A romantic break up[edit]

Physiological and emotional dysregulations occur when one grieves for a loved one, even in situations of severed contact[say what?]. Romantic breakups sometimes lead people to experience rough bereavement symptoms and mood disorders, such as depression. These emotional disturbances can also include exaggerated attempts to re-establish the relationship and angry and vengeful behaviour. Moreover, laboratory studies have been carried out to scrutinize the physiological and biochemical changes associated with bereavement and romantic breakups. Position Emission Tomography has shown that individuals with bereavement symptoms have reduced cerebral blood flow to the hippocampus, with a negative correlation to the severity of the symptoms (Field, 2011). Field (2011) also described that one of the potential underlying mechanisms for heartbreak, breakups and bereavement effects is the loss of social regulators, which disturbs psychological equilibrium, and produces a stress response. He also added, In addition, fMRI studies have noted increased blood flow to the cingulate cortex, which is linked to experiencing feelings of rejection and mixed emotional states. Also, neurotransmitter activity in the emotional experience of love and breakups, such elevated dopamine and norepinephrine levels, and decreased serotonin levels, have been demonstrated to affect heart rate and other physical responses typical for stressful situations. These physiological and biochemical changes are generally indicative of greater occurrence of physical illness, especially heart disease, and may underlie the proposed coronary mechanisms in BHS. Although there is no definitive answer for the mechanism of emotional cause of BHS, experimental studies of bereaved individuals, as well as case studies of grieving individuals with BHS, demonstrate a correlation between the aforementioned physiological and emotional dysregulations, and the proposed coronary mechanisms of BHS (Field, 2011).

Physical stressors[edit]

Physical stressors can be related to physical activities, medical conditions, respiratory failure (e.g:Asthama), pancreatitis and traumatic injury. Drug use such as cocaine and heroin may also cause BHS. Moreover, pregnancy, unusual situations such as lightning strike, near drowning experience, hypothermia, alcohol or opiate withdrawal, and carbon-monoxide poisoning may also trigger BHS (Ghadri et al., 2018).

The relation between broken heart syndrome and mental health[edit]

The fact that severe emotional stress can trigger broken- heart syndrome has been known since the syndrome was first described, and hence it was also termed stress-induced cardiomyopathy (Omerovic, Redfors and Shao, 2013). Two reviews from the American BHS cohorts found that; anxiety and chronic stress were both associated with higher probability of developing broken- heart syndrome. Also, depression and broken heart syndrome had a strong positive correlation (Omerovic, Redfors and Shao, 2013). They mentioned that the study was consistent with research done previously that reported that increased premorbid psychiatric diagnoses, anxiety in particular, have an increased prevalence of broken-heart syndrome. In a study by Omerovic, Redfors and Shao (2013), they also commented on a survey that found that 16% of postmenopausal women reported depressive symptoms, and these symptoms were associated with cardiovascular conditions in the broken- heart syndrome patient category. They also proposed that chronic stress and depression cause structural changes in the cerebrum, which cause shrinking in the hippocampus and loss of grey matter in the prefrontal cortex. These structural changes are linked to alternate hypothalamic-pituitary-adrenal axis response to stress (Omerovic, Redfors and Shao, 2013). They believed that broken heart syndrome may occur minutely in biological predisposed patients in response to stressors, and these predispositions may be triggered by prolonged stress or poor well-being. Omeric, Redfors and shao (2013) finally proposed that broken- heart syndrome is a cardiac syndrome that is linked to other syndromes, especially in the brain. Although the treatment of this condition is in the hands of cardiologists, other experts like psychiatrists or psychologist may help in early detection, and may also help in successfully prevention of reoccurrence by providing emotional support, and by helping patients with various coping strategies to deal with stressors (Omerovic, Redfors and Shao, 2013).

Dissociative amnesia[edit]

Dissociative amnesia[[3]] and BHS are both linked to the elevation of catecholamines. Dissociative amnesia is a memory disorder that is characterized by retrograde memory loss, and an inability to recall personal information, that occurs for a period of time ranging from hours to years after a stressful event (Toussi, Bryk & Alam, 2014). In the case of 66 year- old female named K.D., she was diagnosed with both BHS and dissociative amnesia after the sudden death of her sister. Toussi, Bryk & Alam (2014) reported that it was the first ever case reported where BHS and dissociative amnesia had occurred. Upon the death of K.D.'s sister, K.D. became disoriented and aggressive towards other family members. She initially complained about dyspnea and severe chest pain (Toussi, Bryk & Alam, 2014). She was then escorted outside for some fresh air where she was able to relax for a bit, and then was taken back for evaluation. K.D.'s past medical history included hyperlipidimia, hypertension and gastic ulcers. Her ECG showed that there was a bluge in the left ventricle of the heart and therefore, was diagnosed with BHS. Her mental status was documented as disoriented to place and event and she later had no memory of all the processes she had gone through several hours upon waking up (Toussi, Bryk & Alam, 2014). What they concluded after this case study was that, BHS is frequently triggered by emotional and physical stress. The etiology of this syndrome is hypothesized to be induced by sudden catecholamine surge that leads to coronary vasospasm and direct cardiac myocardial toxicity. The surge of catecholamines also causes dissociative amnesia and hence, BHS and dissocitave amnesia have a chance of occuring together (Toussi, Bryk & Alam, 2014).

Giff1. Stress

Depression[edit]

In an inter-heart study, a case trial of around 29,000 participants in 52 countries found that psychosocial factors such as stress, anxiety and depression are responsible for around 33% of the population's risk for attaining broken- heart syndrome, and depression in general predicts early-onset of cardiac disease, increased mortality and increased cardiac symptoms, such as chest pain and fatigue (Alosaimi & Hawa, 2009). Furthermore, depression symptoms and psychosocial constructs were predictive factors for broken- heart syndrome and hypertension in many studies. Individuals who used problem solving and social-support seeking strategies dealt better with broken- heart syndrome and people who used more coping avoidance strategies found it more difficult to deal with broken- heart syndrome. Also, these people are associated with greater likelihood of behavioural disengagement, denial, mental disengagement, pessimism and lower social support. Altogether, this leads to severe depressive symptoms. This also leads to increased cortisol and catecholamines which in turn cause depression. During BHS serotonin levels are decreased but surprisingly there is a small release of dopamine (Field, 2011). The changes in chemicals are associated with increased heart rate, trembling, pupil dilation, sleeplessness and loss of appetite (Fisher, 2006).

Seizure[edit]

Epileptic seizure has also been documented to trigger broken- heart syndrome. Epilepsy patients display left ventricular apical akinesia with typical patchy myocardial lesions (Omerovic, Redfors and Shao, 2013). The finding that broken- heart syndrome is secondary to epilepsy seemed to be associated with more severe complications, which has led some authors to believe that broken- heart syndrome can explain some cases of unexpected sudden death in epilepsy (Omerovic, Redfors and Shao, 2013). They also reported that in the general broken- heart syndrome cohort, women are more represented among epileptic patients that develop broken- heart syndrome. Data from hospitals has indicated that there is a significant mortality rate in patients with broken- heart syndrome. Clinical and histological criteria would allow for a better design of clinical studies for broken- heart syndrome (Omerovic, Redfors and Shao, 2013).

Quiz[edit]

1. Which of the following options is NOT a sign of BHS?

Tests show ballooning in the right ventricle
No blockages in the coronary arteries in BHS
Tests show ballooning in the left ventricle
Blood tests shows no sign of heart damage

1

Natural disasters are not a possible cause of Broken Heart Syndrome.

TRUE.
FALSE.

2

Broken- Heart Syndrome, Takotsubo Syndrome and Stress- Induced Syndrome are the same condition.

TRUE.
FALSE.

Case study[edit]

A Missed Penalty Kick Triggered Coronary Death in the Husband and Broken Heart Syndrome in the Wife

The defeat of the Chilean team in the FIFA world cup 2014 caused a coronary heart disease in the husband and broken- heart syndrome in the wife. This happened after a Chilean footballer missed the last penalty shootout (Y-Hassan, Feldt & Stålberg, 2015).

Y-Hassan, Feldt & Stålberg (2015) discussed an important point regarding the trigger factors for broken- heart syndrome experienced by the woman in their study. They discussed that the lady was marked by a series of emotional stress factors, starting with the defeat of her national football team, followed by an intense argument which involved the whole family, and then the day ended with the tragic cardiac arrest of her husband. The last intense emotional stressor was probably the most important factor in triggering her disease (Y-Hassan, Feldt & Stålberg, 2015). There is overwhelming evidence that such stressors may induce broken- heart syndrome. However, the combination of the three other emotional experiences cannot be excluded as trigger factors. Published data on the association between FIFA World Cup tournaments and broken- heart syndrome lack. According to Y-Hassan, Feldt & Stålberg, (2015) there is only one other case of broken- heart syndrome in a 56-year-old man, that was triggered by an emotionally stressful event after the defeat of his favourite football team during the Euro 2012 cup, and their case is the second football-related that is recorded.

What are the treatment options?[edit]

Movahed & Donohue, (2007) outlined different treatment options for broken- heart syndrome. They mentioned that in case of apical thrombus formation, anticoagulation methods should benefit until the left ventricular documentary is recovered. These patients are usually discharged on standard medication for left ventricular dysfunction, for example angiotensin-converting enzyme inhibitors and beta-blockers (Movahed & Donohue, 2007). However, they mentioned that there were no studies to asses the necessity of these medications for recovery. A fixed length of treatment is also not determined by researchers (Movahed & Donohue, 2007). Beta- blocker treatment is said to work on a patients who have a previous history of broken- heart syndrome and present with chest pain and a dynamic left ventricular obstruction. In another journal by Tomofuji et al. (2015), a patient with broken- heart syndrome was treated using intravenous cibenzoline succinate. During hospitalisation, the patient showed excellent functional recovery without any complications. In one study, Mrozek et al. (2016) indicated that broken- heart syndrome can occur at an early stage due to severe acute brain injuries, and when it comes to cardiac output decrease or shock, the best treatment is still a matter of debate.

Many treatment techniques focus specifically on the pathphysiology of the heart, however, the fact that the brain can play a major role cannot be ignored. Does depression cause broken- heart syndrome or does having broken- heart syndrome lead to depression and other mental illnesses? Understanding this is important, as psychologists and psychiatrists will be able to contribute more for the treatment of broken- heart syndrome.

Conclusion[edit]

Over the years, chronic stress, loss, shock or emotional pain was just known to cause disturbances around the chest region, but very little research went into why this happened. Takotsubo cardiomyopathy/ stress- induced syndrome/ broken- heart syndrome is a cardiological condition caused due to chronic stress or sudden stress. People can experience this syndrome most commonly after a heart break and hence the term broken- heart syndrome. The syndrome causes ballooning in the left ventricle and there is an increase in catechaloamine levels and decrease in serotonin. Broken- heart syndrome explains the pathophysiology behind why people feel so down after a distressful event. Broken- heart syndrome does not cause any permanent damage to the heart, nevertheless, it causes immense discomfort around the chest region which can lead an individual to experience serious mental health problems. Depression, anxiety and dissociative amnesia are all linked to broken- heart syndrome. Dissocative amnesia and broken- heart syndrome emerge due to the same physiology, but the link between depression or anxiety with broken- heart syndrome have not yet been explored. The fact that the pathophysiology of broken- heart syndrome has not yet been fully understood makes it difficult to find a proper treatment too. A romantic breakup is not the only thing that can cause broken- heart syndrome, but any emotional stressors that involve the same physiological response, such as unemployment, trauma or loss may trigger broken- heart syndrome. Physical stressors such as medical conditions, respiratory failures (e.g:Asthama) and pancreatitis may cause broken- heart syndrome too. Movahed & Donohue, (2007) noted that in the case of apical thrombus formation, anticoagulation methods should benefit until the left ventricular documentary is recovered, and these patients are usually discharged on standard medications for left ventricular dysfunction, for example angiotensin-converting enzyme inhibitors and beta-blockers.

See also[edit]

References[edit]

Alosaimi, F., & Hawa, R. (2009). Broken heart: Broken mind. Journal Of Psychosomatic Research, 67, 285-287. http://doi.org/10.1016/j.jpsychores.2009.07.012

Christensen, T. E., Bang, L. E., Holmvang, L., Hasbak, P., Kjær, A., Bech, P., & Østergaard, S. D. (2016). Neuroticism, depression and anxiety in takotsubo cardiomyopathy. BMC Cardiovascular Disorders, 16. http://doi.org/10.1186/s12872-016-0277-4

Christoph, M., Ebner, B., Stolte, D., Ibrahim, K., Kolschmann, S., Strasser, R., & Schön, S. (2010). Broken heart syndrome: Tako Tsubo cardiomyopathy associated with an overdose of the serotonin–norepinephrine reuptake inhibitor Venlafaxine. European Neuropsychopharmacology, 20, 594-597. http://doi.org/10.1016/j.euroneuro.2010.03.009

Derrick, D. (2009). The"Broken Heart Syndrome": Understanding Takotsubo Cardiomyopathy. Critical Care Nurse, 29, 49-57. http://doi.org/10.4037/ccn2009451

Field, T. (2011). Romantic Breakups, Heartbreak and Bereavement—Romantic Breakups. Psychology, 02, 382-387. http://doi.org/10.4236/psych.2011.24060

Gerhard Whitworth, R. (2018). Takotsubo cardiomyopathy: Causes, symptoms, diagnosis, and treatment. Retrieved from https://www.medicalnewstoday.com/articles/309547.php

Ghadri, J., Wittstein, I., Prasad, A., Sharkey, S., Dote, K., & Akashi, Y. et al. (2018). International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. European Heart Journal, 39, 2032-2046. http://doi.org/10.1093/eurheartj/ehy076

Is Broken Heart Syndrome Real?. (2018). Retrieved from http://www.heart.org/en/health-topics/cardiomyopathy/what-is-cardiomyopathy-in-adults/is-broken-heart-syndrome-real

Kawano, H., Yamasa, T., Arakawa, S., Matsumoto, Y., Sato, O., & Maemura, K. (2018). We need more useful surrogate markers for the efficacy of beta-blockers for the treatment of Takotsubo cardiomyopathy. Geriatrics & Gerontology International, 18, 817-818. http://doi.org/10.1111/ggi.13319

Lacey, C., Mulder, R., Bridgman, P., Kimber, B., Zarifeh, J., Kennedy, M., & Cameron, V. (2014). Broken heart syndrome — Is it a psychosomatic disorder?. Journal Of Psychosomatic Research, 77, 158-160. http://doi.org/10.1016/j.jpsychores.2014.05.003

Litvinov, I., Kotowycz, M., & Wassmann, S. (2009). Iatrogenic epinephrine-induced reverse Takotsubo cardiomyopathy: direct evidence supporting the role of catecholamines in the pathophysiology of the “broken heart syndrome”. Clinical Research In Cardiology, 98, 457-462. http://doi.org/10.1007/s00392-009-0028-y

Lyon, A., Bossone, E., Schneider, B., Sechtem, U., Citro, R., & Underwood, S. et al. (2015). Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology. European Journal Of Heart Failure, 18, 8-27. http://doi.org/10.1002/ejhf.424

Marina, S. (2017). Tako-Tsubo Cardiomyopathy (Broken-Heart Syndrome). Journal Of Cardiology & Cardiovascular Therapy, 2. http://doi.org/10.19080/jocct.2017.02.555597

Movahed, M., & Donohue, D. (2007). Review: transient left ventricular apical ballooning, broken heart syndrome, ampulla cardiomyopathy, atypical apical ballooning, or Tako-Tsubo cardiomyopathy. Cardiovascular Revascularization Medicine, 8, 289-292. http://doi.org/10.1016/j.carrev.2007.02.001

Mrozek, S., Srairi, M., Marhar, F., Delmas, C., Gaussiat, F., & Abaziou, T. et al. (2016). Successful treatment of inverted Takotsubo cardiomyopathy after severe traumatic brain injury with milrinone after dobutamine failure. Heart & Lung, 45, 406-408. http://doi.org/10.1016/j.hrtlng.2016.06.007

National Heart, Lung, and Blood Institute (NHLBI). (2018). Retrieved from https://www.nhlbi.nih.gov/health-topics/broken-heart-syndrome

Omerovic, E., Redfors, B. and Shao, Y. (2013). Stress-induced cardiomyopathy (Takotsubo) – broken heart and mind?. Vascular Health and Risk Management, p.149.

Tomofuji, K., Ikeda, S., Murakami, C., Ochiumi, Y., Nakamura, M., & Kadota, H. et al. (2015). Takotsubo cardiomyopathy with transient left ventricular obstruction successfully treated with cibenzoline succinate: A case report.Journal Of Cardiology Cases, 11, 155-157. http://doi.org/10.1016/j.jccase.2015.01.005

Toussi, A., Bryk, J., & Alam, A. (2014). Forgetting heart break: a fascinating case of transient left ventricular apical ballooning syndrome associated with dissociative amnesia. General Hospital Psychiatry, 36, 225-227. http://doi.org/10.1016/j.genhosppsych.2013.10.007

Y-Hassan, S., Feldt, K., & Stålberg, M. (2015). A Missed Penalty Kick Triggered Coronary Death in the Husband and Broken Heart Syndrome in the Wife. The American Journal Of Cardiology, 116, 1639-1642. http://doi.org/10.1016/j.amjcard.2015.08.033

External links[edit]

Motivation and emotion/Book/2014/Love and culture

Motivation and emotion/Book/2013/Sadness

Motivation and emotion/Book/2017/Sad music and emotion

Motivation and emotion/Book/2017/Sadness as the longest lasting emotion