It is time for the psychiatric and wider medical world to embrace lessons from the growing science of resilience to treat the wide range of stress-related medical and psychiatric disorders more effectively. Quite often, physicians admonish patients to lower their stress levels, while patients quietly wonder how a lifetime of adversity can be undone, or how to extricate themselves from stressful jobs, relationships, or living environments. In these clinical situations, clinicians need to be prepared to offer concrete suggestions to build protective factors for resilience, rather than presuming that patients can magically get rid of their stressors.
The healing professions can be forgiven for coming late to the science of resilience, since vastly greater research and educational efforts have traditionally focused more on the pathogenic impact of stress and risk factors to generate disease, rather than how to harness the healing potential of biopsychosocial protective factors. It is beyond dispute that specific, well-known adverse childhood events and other developmental factors increase the risk for medical and mental illnesses. When a science of resilience began to emerge in the late 20th century, it became apparent that a subset of high-risk individuals who share a number of biopsychosocial protective factors had relatively healthy life outcomes (Table).1
Protective factors include characteristics of the individual and environmental experiences, and may occur at various developmental stages, but all seem to derive from a small handful of fundamental requirements for resilient functioning: a sense of safety, positive social connections, feelings of competence and control, and positive outlooks. Understanding the neurophysiological systems that underlie resilient functioning is crucial to effectively prescribing to the needs of high-risk patients, and to developing innovative ways to more efficiently induce these systems to build resilience.
Evolution of a sense of safety
The human nervous system evolved to serve the fundamental function of modulating behaviors of approach and avoidance so as to optimize the organism’s chances of survival and reproduction. Polyvagal theory observes that humans engage in a continual sensory process of “neuroception,” involving constant surveillance of afferent inputs to ascertain levels of risk, threat, safety, and opportunity to produce behavioral responses that will best serve the needs of survival and reproduction.2 Depending on the valence of afferent signals of neuroception, neurophysiological states are produced that bias our anticipation of novel or unexpected stimuli and result in behavioral and autonomic responses that respond to situations of risk or opportunity.3
Understanding how neuroception produces neurophysiological states in the autonomic nervous system is crucial to understanding how resilient individuals cope with stress. With the explication of polyvagal mechanisms in the parasympathetic nervous system, we have been able to move beyond simplistic models of stress response. Based on the interpretation of these sensory inputs through the brain, we not only respond to risk and threat with well-known fight, flight, or freeze mechanisms, but also respond to conditions of safety and opportunity by activating key components of the parasympathetic nervous system to promote rest, relaxation, restoration, and social engagement. The most resilient individuals seem to have an ability to adeptly use these complex neurophysiological systems, to defend or recover from threats and trauma, and to seek or generate opportunities that create a sense of safety, control, and social connection.
Dr. Vance is Associate Professor, Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA. Dr. Vance reports no conflicts of interest concerning the subject matter of this article.
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