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Yes, you can cope

Yale Medicine Magazine, 2014 - Autumn


We are more resilient than we think, according to psychiatrists who study how we recover from adversity.

Life is often something less than the proverbial bed of roses—but when Steven M. Southwick, M.D., the Glenn H. Greenberg Professor of Psychiatry, PTSD, and Resilience, worked with people who’d been through wars and famines, earthquakes and hurricanes, violent crime and terrorism, or something more mundane like losing money or going through a divorce, he discovered that most people are far stronger than they had ever imagined.

“Almost everyone experiences a significant traumatic event—a serious accident; the loss of a loved one, job, or home; assault or rape; a natural disaster; or something worse—yet most of us make it through and sometimes even grow stronger,” said Southwick, one of a number of researchers at Yale and elsewhere who are looking at resilience, the human characteristic that helps us make our way through life.

Resilience is an easy concept to understand but a hard one to nail down with scientific precision. It has proven hard to study, and little is known about it. There are only hints of biochemical markers, so in their absence, the American Psychological Association defines resilience as “adapting well in the face of adversity, trauma, tragedy, threats, and even significant sources of stress—such as family and relationship problems, serious health problems, or workplace and financial stresses.” In a sense, it’s similar to how an engineer would define resilience in a material: substances that bounce back to their original shapes when stressed. But in humans, there’s often an additional wrinkle. Think of a green twig that bends in a gale but doesn’t break. After the wind dies down, the twig not only survives but also continues to grow.

Southwick and colleague Dennis S. Charney, M.D., HS ’81, a former Yale professor who is now dean of Icahn School of Medicine at Mount Sinai Hospital in New York, recently pooled their insights in a book titled Resilience: The Science of Mastering Life’s Greatest Challenges. It’s a look at some of the most resilient folks on the planet, from POWs to survivors of 9/11, which examines the latest research—a good deal of it being done at Yale—about what goes on in their brains. The book also explores key characteristics—which can be learned through good coaching and steady practice—that help people roll with the punches.

“In interviewing these extremely resilient people, we kept noticing the same factors coming up again and again,” said Southwick—everything from realistic optimism, the ability to face one’s fears, and a strong moral compass, social support network, and spiritual sense, to mental and physical fitness, the availability of resilient role models, psychological flexibility, and skill in finding purpose and meaning.

Underlying these hallmarks is the right kind of neurophysiology, the components of which a number of Yale researchers, Southwick among them, are uncovering.

Charles A. Morgan III, M.D., FW ’01, associate clinical professor of psychiatry, for example, studies members of the military’s elite special operations force. “Many people try out for special ops, but most don’t get in,” said Morgan. “That selection process is a funnel.”

After some 20 years of working with special ops soldiers, Morgan notes that one factor has become abundantly clear. “These people are different biologically, psychologically, and physiologically from the average person in the general military and civilian populations,” said Morgan. “They’re experts in resilience. They have a tough, tough job that exposes them to constant stress and almost unimaginable trauma, and yet they’re so well suited by temperament and training to the work that the risk of untoward psychological side effects is significantly reduced.”

The rate of post-traumatic stress disorder (PTSD) among soldiers in general is, not surprisingly, higher—between 12 and 15 percent, according to Morgan—than the 8 percent found in the civilian population, but in special ops, it’s remarkably low: between 1 and 2 percent. “This is a paradox, but we’re beginning to understand what’s going on,” he explained.

The brain is constantly under stress, but most of the time and in most people, it’s also perfectly capable of handling the situation, after which it damps down the stress circuitry. One tool is a calm-restoring brain chemical, neuropeptide Y (NPY), which is released alongside the brain’s alarm molecule, norepinephrine. “We’ve found that special ops soldiers have the capacity to release greater amounts of NPY than is typical, and this can blunt the negative impact of norepinephrine and other stress hormones,” said Morgan. “We’ve also shown that these people have higher levels of another stress-protecting neurochemical called DHEA, and we suspect there are other important molecular differences as well.”

There is certainly a genetic component at work here. One of the most compelling studies to examine the gene/environment interaction is research by Joel Gelernter, M.D., a Foundations Fund Professor of Psychiatry and professor of genetics and of neurobiology. Four years ago, in the journal Depression and Anxiety, Gelernter and his colleagues reported on more than 600 adults who’d been in the paths of the unusually severe group of hurricanes that pummeled Florida in 2004. They found a twofold increase in a condition known as generalized anxiety disorder (GAD), and among the GAD sufferers, there was an almost fourfold increase in the occurrence of a gene variant linked to lowered production of NPY.

“We all arrive on the scene different,” said Morgan. “There’s genetic variability, so when life comes your way, there’s a differential impact.”

A growing body of research shows, however, that nonstop, uncontrollable stress is universally problematic. “Higher exposure to adverse life events is related to a reduction in brain volume in the regions important to executive functions, such as reasoning, memory, emotional regulation, and perception,” said Rajita Sinha, Ph.D. ’92, a Foundations Fund Professor of Psychiatry as well as director of the Yale Stress Center, which studies the neurophysiology of stress and ways to deal with it. “Not having any stress in your life is not a good thing,” said Sinha, echoing a well-known quote by stress research pioneer Hans Selye that “the absence of stress is death.”

Fortunately, human evolution has endowed us with the ability to adapt to the many stressors we face. There’s increasing evidence from animal studies, noted Sinha, that recovery is possible, with rats and mice regrowing stress-damaged connections and regaining lost deficits in such key areas as working memory. “During a very stressful period we might be unable to remember the plots of movies and find ourselves more easily distracted,” she said. “But we have developed a wide variety of coping mechanisms in the brain that enable us to avoid damage, learn from stress, and not only keep going but also to grow.”

While there’s no single recipe for resiliency, Sinha explained, there are universal elements that enable people to weather the storms and recover afterward. “Social support, keeping your basic needs well regulated, drinking plenty of water, eating right, getting enough sleep, staying away from alcohol and other drugs, and regular exercise—these are critical,” she said, adding that overcoming stress can be difficult. “People need help, and often they lose a lot or hurt badly before transformation can occur.”

There are also medications—antidepressants and antianxiety drugs among them—that can help in recovery, and there are a variety of therapies aimed at enabling people who’ve been through trauma to get better. “It takes real guts to confront this,” said Southwick. He has used a technique called logotherapy—it’s modeled after psychiatrist and Holocaust survivor Viktor Frankl’s “healing through meaning” insights—with chronic PTSD sufferers at the VA Connecticut Healthcare System in West Haven. “We work to find a way for each vet to participate in some kind of meaningful community service, say, for the homebound to serve meals to elderly shut-ins, or vets who are distressed about kids to work with traumatized youngsters in schools. This is important because altruism is strongly associated with resilience and can generate meaning from adversity, which can be a source of tremendous strength.”

Nietzsche declared that “he who has a ‘why’ to live for can endure almost any ‘how’,” and many trauma sufferers find ways of turning their ordeals into meaningful action plans. Despite his almost lifelong imprisonment, Nelson Mandela found a way to forge an end to apartheid in South Africa. Jerry White, a Brown University undergraduate who lost his leg to a land mine in Israel, helped spearhead a Nobel Peace Prize-winning organization aimed at banning land mines. Parents of children murdered in the Sandy Hook school work to support efforts aimed at curbing gun violence, and people affected by trauma find that trying to help others cope with something similar can give meaning to their lives—and both ease pain and turn it into personal and societal progress.

Southwick has a coping strategy that combines a number of resilience techniques. He is always looking for ways to get stronger and be more resilient, which often means “trying to learn from the many role models we have had the privilege to interview. … I’ve learned to meditate and I really like to exercise, so Dennis Charney and I decided to challenge ourselves by entering a 90-mile three-day kayak race in upstate New York.”

After less than an hour of paddling, Southwick was in agony. He hadn’t trained enough, and his neck and shoulders were hurting. “I thought I’d made a huge mistake and that I’d have to drop out, but then I remembered that I’d entered this event as an experiment in a meditation technique known as mindfulness—a way to ignore all those internal discussions you didn’t actually choose to have and focus intensely and nonjudgmentally on the moment.”

The technique, which can help restore a sense of control and tamp down overactive fear circuits, has recently been introduced as an alternative or complementary treatment for PTSD, and while Southwick felt more than a little discomfort throughout the grueling race, reorienting his thinking helped ease his muscular pain. In short order, he began to enjoy the kayak trip through exquisite Adirondack scenery.

Southwick and Charney didn’t win the race. But by practicing what they’d long been preaching, they managed to finish, resilient to the core. “It was very liberating,” said Southwick. Six weeks later, once the inflammation in his shoulders had subsided, he was again able to pick up a kayak paddle.