SPECIAL REPORT: EXPLORING RESILIENCY
In our psychiatric practices, we naturally focus on psychopathology and the negative effects that adverse and traumatic experiences have on our patients’ mental health. We assess disaster survivors’ maladjustment in order to develop policies for mental health recovery programs. However, the majority of individuals exposed to disasters or other traumatic events do not develop posttraumatic stress disorder (PTSD) or another lasting psychiatric disorder, although they may experience temporary ripples on the surface of their emotional lives and subclinical symptoms for a time.
ALSO IN THIS SPECIAL REPORT
Resiliency and Posttraumatic Growth: Cultural Implications for Psychiatrists
Ping Zheng, MD, PhD; Andreas Maercker, MD, PhD
Resilience and Healthy Aging
Igor Linkov, PhD, MSc; Stephanie Galaitsi, MSEE; Katarzyna Klasa, MPH, BSN; Andrew Wister, PhD
In considering the patients seen by my residents and me, I am often in awe of the tremendous strength that many of them have developed despite experiencing horrific abuse, neglect, disasters, extreme poverty, major losses, and other traumatic events. Some who were severely abused or neglected as children become devoted parents or highly functional adults, albeit with effort. How do we understand this emotional hardiness?1
Resilience is a relatively neglected research topic. A Medline search for medical literature related to “psychological resilience” revealed only 6471 articles, whereas a search for articles related to “PTSD” and “posttraumatic stress” (which does not include other mental health problems associated with trauma) identified 36,682 and 18,823, respectively. In fact, in my own research on biological markers for symptoms and diagnoses of PTSD, depression, and anxiety after disaster, we explored heart rate and blood pressure responses, heart rate vulnerability, and levels of cortisol, interleukin-2, and interleukin-6—yet we did not explore those markers or personal characteristics associated with resilience.
Part of the problem is that resilience is difficult to define. Is it the absence of mental health diagnosis, or is it having temporary symptoms or symptom levels below a defined threshold of distress? Or is it having a fulfilled life and pursuing cherished life goals?
However we define resilience, what factors contribute to it? Are some individuals blessed with a fortunate genetic endowment or temperament? Some research has shown heritability of resilience to range between 33% and 52%. Research on resilience has implicated genetic variations in expression of neuropeptide Y and regulation of the HPA axis, as well as polymorphisms in noradrenergic and dopaminergic systems and serotonin transporter genes.2 Conversely, epigenetic factors involve methylation, demethylation, and histone changes after stress, especially early life stress, which can change gene expression but not DNA structure, for a variable amount of time, contributing to psychiatric vulnerability.3 Does this “hop on, hop off” epigenetic model for stress response inversely explain emotional hardiness? Recent research results point to an association between maternal resilience and increased cellular telomere length in newborns, with longer telomeres important in gene transcription, meiosis, and cellular longevity.4 Can promoting maternal adaptation to stress during pregnancy have protective factors in offspring?
Other biological differences associated with positive or negative adjustment after emotional stressors include, but are by no means limited to, hippocampal volume, HPA axis reactivity, the mesolimbic dopamine pathway, and differences in inflammatory markers such as neuropeptide Y, cytokines, and C-reactive protein—before or after trauma exposure.
Experience is also important in resilience. Would stress inoculation in developmental years—having just enough but not too much exposure to hardship—enable individuals to overcome lifetime adversity? This concept has been noted in different cultures—for example, an African proverb intones, “Smooth seas do not make skillful sailors,” and William Shakespeare wrote, “Sweet are the uses of adversity,” in As You Like It. Moreover, as children learn to face inevitable life challenges, having love and support from parent figures or mentors can be protective.
Other factors have been associated with emotional buoyancy: using active coping mechanisms, cognitive reappraisal of negative thoughts, physical exercise, mindfulness, and meditation.5 Having sufficient social support, higher socioeconomic status, and higher educational levels also protect individuals’ psyches. Thoughtful creators of everything from ancient religious and philosophical texts to modern neurobiological and psychological research have linked resilience and life satisfaction with the wisdom that can come with aging. Thus wisdom, resilience, and better health are promoted by the sharing of life experience lessons from older to younger generations.6
Drawing on the tenets of psychoanalysis, some experts have recommended the use of mature ego defenses, such as creativity, humor, and altruism, in the face of difficulty. Humor and altruism have the particular benefit of drawing others in, thus increasing social support.7
Relevant to our current pandemic, the results of a recent large study of frontline health care workers caring for hospitalized COVID-19 patients linked psychological resilience with positive emotions, self-efficacy, sense of purpose in life, and social support (including leadership support), as well as with avoidance of maladaptive behaviors, such as substance abuse.8
In sum, resilience is a rich but understudied field for psychiatric research. In this Special Report, we are honored to present several expert colleagues’ wisdom on psychiatric resilience in diverse areas.
Dr Tucker is vice chair of education for psychiatry and behavioral sciences, holds the Professor and Arnold and Bess Ungerman Endowed Chair in Psychiatry and the Robert Glenn Rapp Foundation Presidential Professorship of Medicine, and serves in the Adult Mental Health Services at The University of Oklahoma College of Medicine, Oklahoma City.
1. Anthony EJ, Cohler BJ, eds. The Invulnerable Child. Guilford Psychiatry Series. Guilford Press; 1987.
2. Wu G, Feder A, Cohen H, et al. Understanding resilience. Front Behav Neurosci. 2013;7:10.
3. Dudley KJ, Li X, Kobor MS, et al. Epigenetic mechanisms mediating vulnerability and resilience to psychiatric disorders. Neurosci Biobehav Rev. 2011;35(7):1544-1551.
4. Verner G, Epel E, Lahti-Pulkkinen M, et al. Maternal psychological resilience during pregnancy and newborn telomere length: a prospective study. Am J Psychiatry. 2021;178(2):183-192.
5. Southwick SM, Charney DS. The science of resilience: implications for the prevention and treatment of depression. Science. 2012;338(6103):79-82.
6. Jeste DV, Lee EE. The emerging empirical science of wisdom: definition, measurement, neurobiology, longevity, and interventions. Harv Rev Psychiatry. 2019;27(3):127-140.
7. Elisei S, Sciarma T, Verdolini N, Anastasi S. Resilience and depressive disorders. Psychiatr Danub. 2013;25 Suppl 2:S263-267.
8. Pietrzak RH, Feingold JH, Feder A, et al. Psychological resilience in frontline health care workers during the acute phase of the COVID-19 pandemic in New York City. J Clin Psychiatry. 2020;82(1):20I13749. ❒