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6 keys to resilience for PTSD and everyday stress
Ms. M, age 24, works as a magazine editor in New York City. On a December evening, she walks out of the subway and heads to her boyfriend’s apartment, looking forward to unloading her heavy bag and checking her e-mail. Out of nowhere, a man runs up behind her and smashes a huge rock into her head.
She feels momentarily disconnected from her body and surroundings but manages to scream. As the assailant runs away, 2 girls rush to her aid.
Ms. M hurts everywhere. Her glasses have been knocked off, and her orbit is fractured; her eye will require multiple surgeries. She reaches for her cell phone, but it’s slippery with blood. A bystander dials 911, and paramedics arrive within minutes.
Most persons experience trauma during their lives,1 but not usually an attack as severe as Ms. M’s. Post-traumatic stress disorder (PTSD) and other psychopathologies are not inevitable or even common, however, developing in 8% to 12% of trauma survivors.2 Why are some individuals more resilient to trauma than others?
Resilience to stress is associated consistently with at least 6 psychosocial factors: active coping styles, regular physical exercise, a positive outlook, a moral compass, social support, and cognitive flexibility (Table 1). This article describes how motivated persons can enhance these “resilience factors” to become more resistant to everyday stressors and unexpected traumas.
Table 1
6 psychosocial factors that protect against
and aid recovery from posttraumatic stress
| Factor | Definition |
|---|---|
| Active coping style | Problem-solving and managing emotions that accompany stress; learning to face fears |
| Physical exercise | Engaging in physical activity to improve mood and health |
| Positive outlook | Using cognitive-behavioral strategies to enhance optimism and decrease pessimism; embracing humor |
| Moral compass | Developing and living by meaningful principles; putting them into action through altruism |
| Social support | Developing and nurturing friendships; seeking resilient role models and learning from them |
| Cognitive flexibility | Finding good in adverse situations; remaining flexible in one’s approach to solving problems |
1. Active coping style
Resilience is the process of adapting well to stress or trauma (Box 1).3-5 Learning to manage stressful situations requires active coping, which can be conceptualized as 2 types:
- “problem-focused” (working to solve the problem)
- “emotion-focused” (accepting and dealing with emotions caused by the stressor).
Undertaking and mastering difficult tasks appears to be effective in increasing resilience to stress. The “stress inoculation” hypothesis (Box 2)8-11 provides a plausible explanation for the observation that children who learn to cope with stress tend to become hardy adults. Successfully overcoming challenges improves self-confidence and also may alter the neurobiology of the stress response.
Prolonged-exposure therapy. PTSD development and maintenance depend in part on fear conditioning. By avoiding exposure to reminders of their trauma, survivors unwittingly solidify associations between traumatic triggers (people, places, or things that are reminders) and fear. Actively facing fears is necessary to break these associations.
Prolonged-exposure therapy was designed to help patients face their fears.12 As part of therapy, participants retell their trauma stories and engage in avoided activities in a safe environment. This treatment has been found to be highly effective in reducing PTSD symptoms, and its benefits often last longer than those conferred by pharmacologic interventions.13
CASE CONTINUED: Feeling ‘out of sync’
Ms. M remains frightened and angry after 2 months and is referred for psychological evaluation. She is diagnosed with PTSD based on her debilitating symptoms, including flashbacks, frightening nightmares, avoiding the subway, and feeling emotionally numb (which she describes as “being out of sync” with loved ones). Ms. M also complains of difficulty sleeping and irritability.
The therapist initiates prolonged-exposure treatment, including imaginal and in vivo exposure. In imaginal exposure, Ms. M tells and retells her trauma story in the safety of the therapist’s office. To desensitize herself to the memory, she listens to her recorded voice recounting her trauma. In vivo exposure involves homework, such as visiting the attack site during the day with a companion and talking with loved ones about the event. These assignments allow Ms. M to reclaim the life she lost because of severe anxiety and fear associated with anything related to the attack.
Within 3 months, Ms. M’s symptoms have improved and no longer meet DSM-IV-TR criteria for PTSD. She continues to struggle with insomnia, affective constriction, and a sense of social isolation—symptoms that often remit slowly, if at all, in trauma victims despite good treatment. She stays in therapy to work on confronting her fears and finding meaning in her experience.
2. Physical exercise
Exercise is a type of active coping that diminishes negative emotions caused by stress. Regular exercisers report less-frequent depression,14 and exercise has been shown to improve clinical depression in adults.15 Exercise builds physical and emotional hardiness, lifts mood, and improves memory. It produces these health benefits by:
- releasing endorphins and serotonin precursors
- attenuating basal hypothalamic-pituitary-adrenal axis activity
- promoting expression of neurotrophic and neuroprotective factors.16
CASE CONTINUED: Learning to self-soothe
Ms. M learns to read children’s stories to help her fall asleep at night and stave off nightmares. She takes up yoga to combat residual anxiety. She also resumes singing in her local chorus, which includes riding the subway home from rehearsals at 10 pm.
Resilience is the ability to maintain normal functioning despite adversity. It can be viewed as the successful operation of “basic human adaptational systems.” Conversely, depression and posttraumatic stress disorder (PTSD) may be understood, in part, as failure to adapt to stress.
Risk factors for PTSD. Traumas with the highest risk for psychopathology are severe, unpredictable, or uncontrollable and those that involve loss of property or (especially) a loved one, danger to self, or physical injury. PTSD risk also is increased by the cumulative effect of multiple, severe, uncontrollable traumas and personal factors such as:
3. A Positive outlook
Depressed individuals tend to view their problems as permanent and pervasive, whereas those who are resilient see adversity as temporary and limited in scope.
Role of dopamine. Humor and positive emotions have been linked to the dopaminergic reward mechanism in the mesolimbic circuitry. Dopaminergic neurons in the ventral tegmental area fire when a reward is received (Table 2); firing increases when a reward is unexpected or greater than expected. These same neurons release less dopamine when rewards are smaller than expected or not received at all.
Optimists are thought to have a robust dopaminergic response to reward, which is either hypersensitive to rewards and/or resistant to dysregulation under stressful (unrewarding) conditions.20
Undertaking and mastering difficult tasks appears to be an effective way to increase resilience to stress. The “stress inoculation” hypothesis provides a plausible explanation for the observation that children who learn to cope with stress become hardy adults.
Men and women who successfully managed stressful situations in childhood—including death or illness of a parent or sibling, family relocation, and loss of friendship—are more resistant to adulthood stressors, such as divorce, death or major illness of a loved one, and job loss.8 Conversely, individuals who experienced extreme childhood stress that they could not control or master—such as physical and/or sexual abuse—may be more vulnerable to future stressors.
Like vaccination? Organisms develop immunity after exposure to a pathogen’s attenuated form; similarly, they may develop resistance to stress after being exposed to and overcoming mild stressors.9 Immunity to stress is not specific to the type of stressor first encountered; early exposure to manageable stress appears to enhance resilience to many adverse experiences.
Neurobiology of resilience. In a series of studies, Special Forces soldiers had higher blood levels of 2 stress-protective hormones—neuropeptide Y (NPY) and dehydroepiandrosterone (DHEA)—immediately after high-stress interrogations than did soldiers who received lessintensive training.10 These hormones also correlated with better performance under stress.
NPY and DHEA help keep the stress response in check by inhibiting release of norepinephrine, cortisol, and other stress-related hormones under high-stress conditions.11 To what degree genetics, development, and/or training enhance NPY and DHEA release is not clear.
Table 2
Neurobiology of resilience:
Factors that influence physiologic stress response
| Selected neurobiological factors | Effect on stress response |
|---|---|
| Up-regulators | |
| Norepinephrine | Neurohormone and neurotransmitter released by the locus ceruleus in response to stress; sympathetic nervous system mediator; increases autonomic arousal (elevates blood pressure, heart rate); facilitates fear memory formation |
| Cortisol | Glucocorticoid released by adrenals in response to HPA axis activation by locus ceruleus; increases arousal, attention, and fear memory formation; initially adaptive, but prolonged/excess release has harmful systemic effects (hypertension, osteoporosis, immune suppression) |
| Down-regulators | |
| DHEA | Steroid released by adrenal cortex under stress; down-regulates stress response; has antiglucocorticoid activity; may protect against PTSD |
| NPY | Neuropeptide that counters locus ceruleus activity; blocks release of cortisol; anxiolytic |
| Galanin | Neuropeptide that counters locus ceruleus activity; anxiolytic |
| Other neurotransmitters | |
| Dopamine | Optimal levels enable reward system functioning; excess or deficit linked to learned helplessness and stress |
| Serotonin | Mixed effects, but high activity at 5HT1A receptors is linked to resilience |
| DHEA: dehydroepiandrosterone; HPA: hypothalamic-pituitary-adrenal; NPY: neuropeptide Y; PTSD: posttraumatic stress disorder | |
CASE CONTINUED: ‘I’m not bitter’
Ms. M can make an occasional joke about her attack and the massive stacks of paperwork she must sort through to pay medical bills and get reimbursed by insurance. She says, “I’m not bitter. I don’t want to carry that anger around for the rest of my life, so I won’t.”
4. A moral compass
Religious faith is associated with lower rates of depression in many populations, including college students, bereaved adults, and elderly hospitalized patients.21 Religious faith is not essential to a strong moral compass, however.
Morality appears to have a neural basis—a hypothesis supported by the observation that brain injury can damage one’s moral sense. “Acquired sociopathy” can result from trauma to certain brain areas, including the anterior prefrontal cortex and anterior temporal lobes.
‘Required helpfulness.’ Altruism—putting one’s moral compass into action—benefits the person who practices it and the person who receives it. Persons who help others perceive themselves as necessary and derive fulfillment. This phenomenon known as “required helpfulness” was first described during World War II, when those who cared for others after bombardments suffered less posttraumatic psychopathology than those who did not.22
Some individuals find healing in a “survivor mission” after personal tragedy, helping others cope with the same problem they faced. Mothers Against Drunk Driving—founded by mothers who lost children in car accidents—is one example.23
CASE CONTINUED: Altruism in action
Ms. M hopes to prevent attacks on other women. She participates in an organization that teaches women self-defense. She also speaks publicly for women’s safety and works with a local board to help defray crime survivors’ medical costs.
5. Social support
Individuals with strong social support tend to be more resilient than those without.24 Social support can reduce risk-taking behavior, encourage active coping, decrease loneliness, increase feelings of self-worth, and help a person put problems into perspective. A lack of social support correlates with depression, stress, and increased morbidity and mortality during medical illness.
Role models. People can learn to manage stress by mimicking the behavior of someone they respect. Many resilient adults credit a parent, grandparent, or other role model for teaching them to act honestly and inspiring them to be strong. In a study of 770 teenagers, those who had a strong nonparental mentor (such as a neighbor, teacher, or coach) reported less drug use and delinquency and a greater belief in the importance of school than those without such a mentor.25
CASE CONTINUED: Dad’s her role model
When she has bad days, Ms. M draws strength by thinking about her father, who has suffered much and whom she respects.
6. Cognitive flexibility
Being able to positively reframe negative events (“cognitive reappraisal”) is crucial to resilience. Individuals who successfully overcome adverse events usually manage to find some meaning in their tragedy.
Psychiatrist and Holocaust survivor Viktor Frankl26 wrote of the importance of “meaning making.” Despite suffering for years in Nazi concentration camps, Frankl wrote that he gained the opportunity to exercise inner strength and be “brave, dignified and unselfish.” He struggled to survive because he came to believe that his suffering had a purpose: to live to teach others about his experiences.
Neuroimaging studies indicate that individuals who use cognitive reappraisal to deal with adversity have strong “top-down control” of emotions. They can modify their reaction to stress or trauma by activating the prefrontal cortex, which then modulates amygdalar response to the situation.27
CASE CONTINUED: Reappraisal
Although Ms. M wishes she had never been attacked and can find no rational explanation for it, she is weaving the event into the fabric of her life. She insists she has become stronger, wiser, and safer and wants to share her story with others.
Related resources
- National Center for Posttraumatic Stress Disorder. U.S. Department of Veterans Affairs. www.ncptsd.va.gov.
- The road to resilience. American Psychological Association Help Center. www.apahelpcenter.org/featuredtopics/feature.php?id=6.
- Positive Psychology Center. University of Pennsylvania. www.ppc.sas.upenn.edu.
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Frans O, Rimmo PA, Aberg L, Fredrikson M. Trauma exposure and post-traumatic stress disorder in the general population. Acta Psychiatr Scand 2005;111(4):291-9.
2. Breslau N, Davis GC, Andreski P, Peterson E. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 1991;48(3):216-22.
3. Fauerbach JA, Lawrence JW, Schmidt CW, Jr, et al. Personality predictors of injury-related posttraumatic stress disorder. J Nerv Ment Dis 2000;188(8):510-7.
4. Masten AS. Ordinary magic. Resilience processes in development. Am Psychol 2001;56(3):227-38.
5. Nemeroff CB, Bremner JD, Foa EB, et al. Posttraumatic stress disorder: a state-of-the-science review. J Psychiatr Res 2006;40(1):1-21.
6. Park CL, Adler NE. Coping style as a predictor of health and well-being across the first year of medical school. Health Psychol 2003;22(6):627-31.
7. Muris P, Schmidt H, Lambrichs R, Meesters C. Protective and vulnerability factors of depression in normal adolescents. Behav Res Ther 2001;39(5):555-65.
8. Khoshaba DM, Maddi SR. Early experiences in hardiness development. Consulting Psychology Journal: Practice and Research 1999;51(2):106-16.
9. Rutter M. Resilience: some conceptual considerations. J Adolesc Health 1993;14(8):626-31,690-6.
10. Morgan CA, 3rd, Wang S, Southwick SM, et al. Plasma neuropeptide-Y concentrations in humans exposed to military survival training. Biol Psychiatry 2000;47(10):902-9.
11. Heilig M, Koob GF, Ekman R, Britton KT. Corticotropin-releasing factor and neuropeptide Y: role in emotional integration. Trends Neurosci 1994;17(2):80-5.
12. Foa EB, Rothbaum BO. Treating the trauma of rape: cognitive behavioral therapy for PTSD. New York: Guilford Press; 1998.
13. Foa EB, Dancu CV, Hembree EA, et al. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. J Consult Clin Psychol 1999;67(2):194-200.
14. Brosse AL, Sheets ES, Lett HS, Blumenthal JA. Exercise and the treatment of clinical depression in adults: recent findings and future directions. Sports Med 2002;32(12):741-60.
15. Singh NA, Clements KM, Singh MA. The efficacy of exercise as a long-term antidepressant in elderly subjects: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci 2001;56(8):M497-504.
16. Cotman CW, Berchtold NC. Exercise: a behavioral intervention to enhance brain health and plasticity. Trends Neurosci 2002;25(6):295-301.
17. Dishman RK, Berthoud HR, Booth FW, et al. Neurobiology of exercise. Obesity (Silver Spring) 2006;14(3):345-56.
18. Fredrickson BL. The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions. Am Psychol 2001;56(3):218-26.
19. Folkman S. Positive psychological states and coping with severe stress. Soc Sci Med 1997;45(8):1207-21.
20. Charney DS. Psychobiological mechanisms of resilience and vulnerability: implications for successful adaptation to extreme stress. Am J Psychiatry 2004;161(2):195-216.
21. Koenig HG, George LK, Peterson BL. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry 1998;155(4):536-42.
22. Rachman S. The concept of required helpfulness. Behav Res Ther 1979;17(1):1-6.
23. Southwick SM, Vythilingham M, Charney DS. The psychobiology of depression and resilience to stress: implications for prevention and treatment. Annual Review of Clinical Psychology 2005;1:255-91.
24. Resick PA. Clinical psychology: a modular course. Philadelphia: Taylor & Francis Group; 2001.
25. Rhodes JE, Roffman J, Grossman JB. The rhetoric and reality of youth mentoring. In: Rhodes JE, ed. New directions in youth development: theory, practice, and research—a critical view of youth mentoring. San Francisco: Jossey-Bass; 2002: 9-20.
26. Frankl VE. Man’s search for meaning. Boston: Beacon Press; 1959:75-7.
27. Ochsner KN, Ray RD, Cooper JC, et al. For better or for worse: neural systems supporting the cognitive down- and up-regulation of negative emotion. Neuroimage 2004;23(2):483-99.
Ms. M, age 24, works as a magazine editor in New York City. On a December evening, she walks out of the subway and heads to her boyfriend’s apartment, looking forward to unloading her heavy bag and checking her e-mail. Out of nowhere, a man runs up behind her and smashes a huge rock into her head.
She feels momentarily disconnected from her body and surroundings but manages to scream. As the assailant runs away, 2 girls rush to her aid.
Ms. M hurts everywhere. Her glasses have been knocked off, and her orbit is fractured; her eye will require multiple surgeries. She reaches for her cell phone, but it’s slippery with blood. A bystander dials 911, and paramedics arrive within minutes.
Most persons experience trauma during their lives,1 but not usually an attack as severe as Ms. M’s. Post-traumatic stress disorder (PTSD) and other psychopathologies are not inevitable or even common, however, developing in 8% to 12% of trauma survivors.2 Why are some individuals more resilient to trauma than others?
Resilience to stress is associated consistently with at least 6 psychosocial factors: active coping styles, regular physical exercise, a positive outlook, a moral compass, social support, and cognitive flexibility (Table 1). This article describes how motivated persons can enhance these “resilience factors” to become more resistant to everyday stressors and unexpected traumas.
Table 1
6 psychosocial factors that protect against
and aid recovery from posttraumatic stress
| Factor | Definition |
|---|---|
| Active coping style | Problem-solving and managing emotions that accompany stress; learning to face fears |
| Physical exercise | Engaging in physical activity to improve mood and health |
| Positive outlook | Using cognitive-behavioral strategies to enhance optimism and decrease pessimism; embracing humor |
| Moral compass | Developing and living by meaningful principles; putting them into action through altruism |
| Social support | Developing and nurturing friendships; seeking resilient role models and learning from them |
| Cognitive flexibility | Finding good in adverse situations; remaining flexible in one’s approach to solving problems |
1. Active coping style
Resilience is the process of adapting well to stress or trauma (Box 1).3-5 Learning to manage stressful situations requires active coping, which can be conceptualized as 2 types:
- “problem-focused” (working to solve the problem)
- “emotion-focused” (accepting and dealing with emotions caused by the stressor).
Undertaking and mastering difficult tasks appears to be effective in increasing resilience to stress. The “stress inoculation” hypothesis (Box 2)8-11 provides a plausible explanation for the observation that children who learn to cope with stress tend to become hardy adults. Successfully overcoming challenges improves self-confidence and also may alter the neurobiology of the stress response.
Prolonged-exposure therapy. PTSD development and maintenance depend in part on fear conditioning. By avoiding exposure to reminders of their trauma, survivors unwittingly solidify associations between traumatic triggers (people, places, or things that are reminders) and fear. Actively facing fears is necessary to break these associations.
Prolonged-exposure therapy was designed to help patients face their fears.12 As part of therapy, participants retell their trauma stories and engage in avoided activities in a safe environment. This treatment has been found to be highly effective in reducing PTSD symptoms, and its benefits often last longer than those conferred by pharmacologic interventions.13
CASE CONTINUED: Feeling ‘out of sync’
Ms. M remains frightened and angry after 2 months and is referred for psychological evaluation. She is diagnosed with PTSD based on her debilitating symptoms, including flashbacks, frightening nightmares, avoiding the subway, and feeling emotionally numb (which she describes as “being out of sync” with loved ones). Ms. M also complains of difficulty sleeping and irritability.
The therapist initiates prolonged-exposure treatment, including imaginal and in vivo exposure. In imaginal exposure, Ms. M tells and retells her trauma story in the safety of the therapist’s office. To desensitize herself to the memory, she listens to her recorded voice recounting her trauma. In vivo exposure involves homework, such as visiting the attack site during the day with a companion and talking with loved ones about the event. These assignments allow Ms. M to reclaim the life she lost because of severe anxiety and fear associated with anything related to the attack.
Within 3 months, Ms. M’s symptoms have improved and no longer meet DSM-IV-TR criteria for PTSD. She continues to struggle with insomnia, affective constriction, and a sense of social isolation—symptoms that often remit slowly, if at all, in trauma victims despite good treatment. She stays in therapy to work on confronting her fears and finding meaning in her experience.
2. Physical exercise
Exercise is a type of active coping that diminishes negative emotions caused by stress. Regular exercisers report less-frequent depression,14 and exercise has been shown to improve clinical depression in adults.15 Exercise builds physical and emotional hardiness, lifts mood, and improves memory. It produces these health benefits by:
- releasing endorphins and serotonin precursors
- attenuating basal hypothalamic-pituitary-adrenal axis activity
- promoting expression of neurotrophic and neuroprotective factors.16
CASE CONTINUED: Learning to self-soothe
Ms. M learns to read children’s stories to help her fall asleep at night and stave off nightmares. She takes up yoga to combat residual anxiety. She also resumes singing in her local chorus, which includes riding the subway home from rehearsals at 10 pm.
Resilience is the ability to maintain normal functioning despite adversity. It can be viewed as the successful operation of “basic human adaptational systems.” Conversely, depression and posttraumatic stress disorder (PTSD) may be understood, in part, as failure to adapt to stress.
Risk factors for PTSD. Traumas with the highest risk for psychopathology are severe, unpredictable, or uncontrollable and those that involve loss of property or (especially) a loved one, danger to self, or physical injury. PTSD risk also is increased by the cumulative effect of multiple, severe, uncontrollable traumas and personal factors such as:
3. A Positive outlook
Depressed individuals tend to view their problems as permanent and pervasive, whereas those who are resilient see adversity as temporary and limited in scope.
Role of dopamine. Humor and positive emotions have been linked to the dopaminergic reward mechanism in the mesolimbic circuitry. Dopaminergic neurons in the ventral tegmental area fire when a reward is received (Table 2); firing increases when a reward is unexpected or greater than expected. These same neurons release less dopamine when rewards are smaller than expected or not received at all.
Optimists are thought to have a robust dopaminergic response to reward, which is either hypersensitive to rewards and/or resistant to dysregulation under stressful (unrewarding) conditions.20
Undertaking and mastering difficult tasks appears to be an effective way to increase resilience to stress. The “stress inoculation” hypothesis provides a plausible explanation for the observation that children who learn to cope with stress become hardy adults.
Men and women who successfully managed stressful situations in childhood—including death or illness of a parent or sibling, family relocation, and loss of friendship—are more resistant to adulthood stressors, such as divorce, death or major illness of a loved one, and job loss.8 Conversely, individuals who experienced extreme childhood stress that they could not control or master—such as physical and/or sexual abuse—may be more vulnerable to future stressors.
Like vaccination? Organisms develop immunity after exposure to a pathogen’s attenuated form; similarly, they may develop resistance to stress after being exposed to and overcoming mild stressors.9 Immunity to stress is not specific to the type of stressor first encountered; early exposure to manageable stress appears to enhance resilience to many adverse experiences.
Neurobiology of resilience. In a series of studies, Special Forces soldiers had higher blood levels of 2 stress-protective hormones—neuropeptide Y (NPY) and dehydroepiandrosterone (DHEA)—immediately after high-stress interrogations than did soldiers who received lessintensive training.10 These hormones also correlated with better performance under stress.
NPY and DHEA help keep the stress response in check by inhibiting release of norepinephrine, cortisol, and other stress-related hormones under high-stress conditions.11 To what degree genetics, development, and/or training enhance NPY and DHEA release is not clear.
Table 2
Neurobiology of resilience:
Factors that influence physiologic stress response
| Selected neurobiological factors | Effect on stress response |
|---|---|
| Up-regulators | |
| Norepinephrine | Neurohormone and neurotransmitter released by the locus ceruleus in response to stress; sympathetic nervous system mediator; increases autonomic arousal (elevates blood pressure, heart rate); facilitates fear memory formation |
| Cortisol | Glucocorticoid released by adrenals in response to HPA axis activation by locus ceruleus; increases arousal, attention, and fear memory formation; initially adaptive, but prolonged/excess release has harmful systemic effects (hypertension, osteoporosis, immune suppression) |
| Down-regulators | |
| DHEA | Steroid released by adrenal cortex under stress; down-regulates stress response; has antiglucocorticoid activity; may protect against PTSD |
| NPY | Neuropeptide that counters locus ceruleus activity; blocks release of cortisol; anxiolytic |
| Galanin | Neuropeptide that counters locus ceruleus activity; anxiolytic |
| Other neurotransmitters | |
| Dopamine | Optimal levels enable reward system functioning; excess or deficit linked to learned helplessness and stress |
| Serotonin | Mixed effects, but high activity at 5HT1A receptors is linked to resilience |
| DHEA: dehydroepiandrosterone; HPA: hypothalamic-pituitary-adrenal; NPY: neuropeptide Y; PTSD: posttraumatic stress disorder | |
CASE CONTINUED: ‘I’m not bitter’
Ms. M can make an occasional joke about her attack and the massive stacks of paperwork she must sort through to pay medical bills and get reimbursed by insurance. She says, “I’m not bitter. I don’t want to carry that anger around for the rest of my life, so I won’t.”
4. A moral compass
Religious faith is associated with lower rates of depression in many populations, including college students, bereaved adults, and elderly hospitalized patients.21 Religious faith is not essential to a strong moral compass, however.
Morality appears to have a neural basis—a hypothesis supported by the observation that brain injury can damage one’s moral sense. “Acquired sociopathy” can result from trauma to certain brain areas, including the anterior prefrontal cortex and anterior temporal lobes.
‘Required helpfulness.’ Altruism—putting one’s moral compass into action—benefits the person who practices it and the person who receives it. Persons who help others perceive themselves as necessary and derive fulfillment. This phenomenon known as “required helpfulness” was first described during World War II, when those who cared for others after bombardments suffered less posttraumatic psychopathology than those who did not.22
Some individuals find healing in a “survivor mission” after personal tragedy, helping others cope with the same problem they faced. Mothers Against Drunk Driving—founded by mothers who lost children in car accidents—is one example.23
CASE CONTINUED: Altruism in action
Ms. M hopes to prevent attacks on other women. She participates in an organization that teaches women self-defense. She also speaks publicly for women’s safety and works with a local board to help defray crime survivors’ medical costs.
5. Social support
Individuals with strong social support tend to be more resilient than those without.24 Social support can reduce risk-taking behavior, encourage active coping, decrease loneliness, increase feelings of self-worth, and help a person put problems into perspective. A lack of social support correlates with depression, stress, and increased morbidity and mortality during medical illness.
Role models. People can learn to manage stress by mimicking the behavior of someone they respect. Many resilient adults credit a parent, grandparent, or other role model for teaching them to act honestly and inspiring them to be strong. In a study of 770 teenagers, those who had a strong nonparental mentor (such as a neighbor, teacher, or coach) reported less drug use and delinquency and a greater belief in the importance of school than those without such a mentor.25
CASE CONTINUED: Dad’s her role model
When she has bad days, Ms. M draws strength by thinking about her father, who has suffered much and whom she respects.
6. Cognitive flexibility
Being able to positively reframe negative events (“cognitive reappraisal”) is crucial to resilience. Individuals who successfully overcome adverse events usually manage to find some meaning in their tragedy.
Psychiatrist and Holocaust survivor Viktor Frankl26 wrote of the importance of “meaning making.” Despite suffering for years in Nazi concentration camps, Frankl wrote that he gained the opportunity to exercise inner strength and be “brave, dignified and unselfish.” He struggled to survive because he came to believe that his suffering had a purpose: to live to teach others about his experiences.
Neuroimaging studies indicate that individuals who use cognitive reappraisal to deal with adversity have strong “top-down control” of emotions. They can modify their reaction to stress or trauma by activating the prefrontal cortex, which then modulates amygdalar response to the situation.27
CASE CONTINUED: Reappraisal
Although Ms. M wishes she had never been attacked and can find no rational explanation for it, she is weaving the event into the fabric of her life. She insists she has become stronger, wiser, and safer and wants to share her story with others.
Related resources
- National Center for Posttraumatic Stress Disorder. U.S. Department of Veterans Affairs. www.ncptsd.va.gov.
- The road to resilience. American Psychological Association Help Center. www.apahelpcenter.org/featuredtopics/feature.php?id=6.
- Positive Psychology Center. University of Pennsylvania. www.ppc.sas.upenn.edu.
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Ms. M, age 24, works as a magazine editor in New York City. On a December evening, she walks out of the subway and heads to her boyfriend’s apartment, looking forward to unloading her heavy bag and checking her e-mail. Out of nowhere, a man runs up behind her and smashes a huge rock into her head.
She feels momentarily disconnected from her body and surroundings but manages to scream. As the assailant runs away, 2 girls rush to her aid.
Ms. M hurts everywhere. Her glasses have been knocked off, and her orbit is fractured; her eye will require multiple surgeries. She reaches for her cell phone, but it’s slippery with blood. A bystander dials 911, and paramedics arrive within minutes.
Most persons experience trauma during their lives,1 but not usually an attack as severe as Ms. M’s. Post-traumatic stress disorder (PTSD) and other psychopathologies are not inevitable or even common, however, developing in 8% to 12% of trauma survivors.2 Why are some individuals more resilient to trauma than others?
Resilience to stress is associated consistently with at least 6 psychosocial factors: active coping styles, regular physical exercise, a positive outlook, a moral compass, social support, and cognitive flexibility (Table 1). This article describes how motivated persons can enhance these “resilience factors” to become more resistant to everyday stressors and unexpected traumas.
Table 1
6 psychosocial factors that protect against
and aid recovery from posttraumatic stress
| Factor | Definition |
|---|---|
| Active coping style | Problem-solving and managing emotions that accompany stress; learning to face fears |
| Physical exercise | Engaging in physical activity to improve mood and health |
| Positive outlook | Using cognitive-behavioral strategies to enhance optimism and decrease pessimism; embracing humor |
| Moral compass | Developing and living by meaningful principles; putting them into action through altruism |
| Social support | Developing and nurturing friendships; seeking resilient role models and learning from them |
| Cognitive flexibility | Finding good in adverse situations; remaining flexible in one’s approach to solving problems |
1. Active coping style
Resilience is the process of adapting well to stress or trauma (Box 1).3-5 Learning to manage stressful situations requires active coping, which can be conceptualized as 2 types:
- “problem-focused” (working to solve the problem)
- “emotion-focused” (accepting and dealing with emotions caused by the stressor).
Undertaking and mastering difficult tasks appears to be effective in increasing resilience to stress. The “stress inoculation” hypothesis (Box 2)8-11 provides a plausible explanation for the observation that children who learn to cope with stress tend to become hardy adults. Successfully overcoming challenges improves self-confidence and also may alter the neurobiology of the stress response.
Prolonged-exposure therapy. PTSD development and maintenance depend in part on fear conditioning. By avoiding exposure to reminders of their trauma, survivors unwittingly solidify associations between traumatic triggers (people, places, or things that are reminders) and fear. Actively facing fears is necessary to break these associations.
Prolonged-exposure therapy was designed to help patients face their fears.12 As part of therapy, participants retell their trauma stories and engage in avoided activities in a safe environment. This treatment has been found to be highly effective in reducing PTSD symptoms, and its benefits often last longer than those conferred by pharmacologic interventions.13
CASE CONTINUED: Feeling ‘out of sync’
Ms. M remains frightened and angry after 2 months and is referred for psychological evaluation. She is diagnosed with PTSD based on her debilitating symptoms, including flashbacks, frightening nightmares, avoiding the subway, and feeling emotionally numb (which she describes as “being out of sync” with loved ones). Ms. M also complains of difficulty sleeping and irritability.
The therapist initiates prolonged-exposure treatment, including imaginal and in vivo exposure. In imaginal exposure, Ms. M tells and retells her trauma story in the safety of the therapist’s office. To desensitize herself to the memory, she listens to her recorded voice recounting her trauma. In vivo exposure involves homework, such as visiting the attack site during the day with a companion and talking with loved ones about the event. These assignments allow Ms. M to reclaim the life she lost because of severe anxiety and fear associated with anything related to the attack.
Within 3 months, Ms. M’s symptoms have improved and no longer meet DSM-IV-TR criteria for PTSD. She continues to struggle with insomnia, affective constriction, and a sense of social isolation—symptoms that often remit slowly, if at all, in trauma victims despite good treatment. She stays in therapy to work on confronting her fears and finding meaning in her experience.
2. Physical exercise
Exercise is a type of active coping that diminishes negative emotions caused by stress. Regular exercisers report less-frequent depression,14 and exercise has been shown to improve clinical depression in adults.15 Exercise builds physical and emotional hardiness, lifts mood, and improves memory. It produces these health benefits by:
- releasing endorphins and serotonin precursors
- attenuating basal hypothalamic-pituitary-adrenal axis activity
- promoting expression of neurotrophic and neuroprotective factors.16
CASE CONTINUED: Learning to self-soothe
Ms. M learns to read children’s stories to help her fall asleep at night and stave off nightmares. She takes up yoga to combat residual anxiety. She also resumes singing in her local chorus, which includes riding the subway home from rehearsals at 10 pm.
Resilience is the ability to maintain normal functioning despite adversity. It can be viewed as the successful operation of “basic human adaptational systems.” Conversely, depression and posttraumatic stress disorder (PTSD) may be understood, in part, as failure to adapt to stress.
Risk factors for PTSD. Traumas with the highest risk for psychopathology are severe, unpredictable, or uncontrollable and those that involve loss of property or (especially) a loved one, danger to self, or physical injury. PTSD risk also is increased by the cumulative effect of multiple, severe, uncontrollable traumas and personal factors such as:
3. A Positive outlook
Depressed individuals tend to view their problems as permanent and pervasive, whereas those who are resilient see adversity as temporary and limited in scope.
Role of dopamine. Humor and positive emotions have been linked to the dopaminergic reward mechanism in the mesolimbic circuitry. Dopaminergic neurons in the ventral tegmental area fire when a reward is received (Table 2); firing increases when a reward is unexpected or greater than expected. These same neurons release less dopamine when rewards are smaller than expected or not received at all.
Optimists are thought to have a robust dopaminergic response to reward, which is either hypersensitive to rewards and/or resistant to dysregulation under stressful (unrewarding) conditions.20
Undertaking and mastering difficult tasks appears to be an effective way to increase resilience to stress. The “stress inoculation” hypothesis provides a plausible explanation for the observation that children who learn to cope with stress become hardy adults.
Men and women who successfully managed stressful situations in childhood—including death or illness of a parent or sibling, family relocation, and loss of friendship—are more resistant to adulthood stressors, such as divorce, death or major illness of a loved one, and job loss.8 Conversely, individuals who experienced extreme childhood stress that they could not control or master—such as physical and/or sexual abuse—may be more vulnerable to future stressors.
Like vaccination? Organisms develop immunity after exposure to a pathogen’s attenuated form; similarly, they may develop resistance to stress after being exposed to and overcoming mild stressors.9 Immunity to stress is not specific to the type of stressor first encountered; early exposure to manageable stress appears to enhance resilience to many adverse experiences.
Neurobiology of resilience. In a series of studies, Special Forces soldiers had higher blood levels of 2 stress-protective hormones—neuropeptide Y (NPY) and dehydroepiandrosterone (DHEA)—immediately after high-stress interrogations than did soldiers who received lessintensive training.10 These hormones also correlated with better performance under stress.
NPY and DHEA help keep the stress response in check by inhibiting release of norepinephrine, cortisol, and other stress-related hormones under high-stress conditions.11 To what degree genetics, development, and/or training enhance NPY and DHEA release is not clear.
Table 2
Neurobiology of resilience:
Factors that influence physiologic stress response
| Selected neurobiological factors | Effect on stress response |
|---|---|
| Up-regulators | |
| Norepinephrine | Neurohormone and neurotransmitter released by the locus ceruleus in response to stress; sympathetic nervous system mediator; increases autonomic arousal (elevates blood pressure, heart rate); facilitates fear memory formation |
| Cortisol | Glucocorticoid released by adrenals in response to HPA axis activation by locus ceruleus; increases arousal, attention, and fear memory formation; initially adaptive, but prolonged/excess release has harmful systemic effects (hypertension, osteoporosis, immune suppression) |
| Down-regulators | |
| DHEA | Steroid released by adrenal cortex under stress; down-regulates stress response; has antiglucocorticoid activity; may protect against PTSD |
| NPY | Neuropeptide that counters locus ceruleus activity; blocks release of cortisol; anxiolytic |
| Galanin | Neuropeptide that counters locus ceruleus activity; anxiolytic |
| Other neurotransmitters | |
| Dopamine | Optimal levels enable reward system functioning; excess or deficit linked to learned helplessness and stress |
| Serotonin | Mixed effects, but high activity at 5HT1A receptors is linked to resilience |
| DHEA: dehydroepiandrosterone; HPA: hypothalamic-pituitary-adrenal; NPY: neuropeptide Y; PTSD: posttraumatic stress disorder | |
CASE CONTINUED: ‘I’m not bitter’
Ms. M can make an occasional joke about her attack and the massive stacks of paperwork she must sort through to pay medical bills and get reimbursed by insurance. She says, “I’m not bitter. I don’t want to carry that anger around for the rest of my life, so I won’t.”
4. A moral compass
Religious faith is associated with lower rates of depression in many populations, including college students, bereaved adults, and elderly hospitalized patients.21 Religious faith is not essential to a strong moral compass, however.
Morality appears to have a neural basis—a hypothesis supported by the observation that brain injury can damage one’s moral sense. “Acquired sociopathy” can result from trauma to certain brain areas, including the anterior prefrontal cortex and anterior temporal lobes.
‘Required helpfulness.’ Altruism—putting one’s moral compass into action—benefits the person who practices it and the person who receives it. Persons who help others perceive themselves as necessary and derive fulfillment. This phenomenon known as “required helpfulness” was first described during World War II, when those who cared for others after bombardments suffered less posttraumatic psychopathology than those who did not.22
Some individuals find healing in a “survivor mission” after personal tragedy, helping others cope with the same problem they faced. Mothers Against Drunk Driving—founded by mothers who lost children in car accidents—is one example.23
CASE CONTINUED: Altruism in action
Ms. M hopes to prevent attacks on other women. She participates in an organization that teaches women self-defense. She also speaks publicly for women’s safety and works with a local board to help defray crime survivors’ medical costs.
5. Social support
Individuals with strong social support tend to be more resilient than those without.24 Social support can reduce risk-taking behavior, encourage active coping, decrease loneliness, increase feelings of self-worth, and help a person put problems into perspective. A lack of social support correlates with depression, stress, and increased morbidity and mortality during medical illness.
Role models. People can learn to manage stress by mimicking the behavior of someone they respect. Many resilient adults credit a parent, grandparent, or other role model for teaching them to act honestly and inspiring them to be strong. In a study of 770 teenagers, those who had a strong nonparental mentor (such as a neighbor, teacher, or coach) reported less drug use and delinquency and a greater belief in the importance of school than those without such a mentor.25
CASE CONTINUED: Dad’s her role model
When she has bad days, Ms. M draws strength by thinking about her father, who has suffered much and whom she respects.
6. Cognitive flexibility
Being able to positively reframe negative events (“cognitive reappraisal”) is crucial to resilience. Individuals who successfully overcome adverse events usually manage to find some meaning in their tragedy.
Psychiatrist and Holocaust survivor Viktor Frankl26 wrote of the importance of “meaning making.” Despite suffering for years in Nazi concentration camps, Frankl wrote that he gained the opportunity to exercise inner strength and be “brave, dignified and unselfish.” He struggled to survive because he came to believe that his suffering had a purpose: to live to teach others about his experiences.
Neuroimaging studies indicate that individuals who use cognitive reappraisal to deal with adversity have strong “top-down control” of emotions. They can modify their reaction to stress or trauma by activating the prefrontal cortex, which then modulates amygdalar response to the situation.27
CASE CONTINUED: Reappraisal
Although Ms. M wishes she had never been attacked and can find no rational explanation for it, she is weaving the event into the fabric of her life. She insists she has become stronger, wiser, and safer and wants to share her story with others.
Related resources
- National Center for Posttraumatic Stress Disorder. U.S. Department of Veterans Affairs. www.ncptsd.va.gov.
- The road to resilience. American Psychological Association Help Center. www.apahelpcenter.org/featuredtopics/feature.php?id=6.
- Positive Psychology Center. University of Pennsylvania. www.ppc.sas.upenn.edu.
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Frans O, Rimmo PA, Aberg L, Fredrikson M. Trauma exposure and post-traumatic stress disorder in the general population. Acta Psychiatr Scand 2005;111(4):291-9.
2. Breslau N, Davis GC, Andreski P, Peterson E. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 1991;48(3):216-22.
3. Fauerbach JA, Lawrence JW, Schmidt CW, Jr, et al. Personality predictors of injury-related posttraumatic stress disorder. J Nerv Ment Dis 2000;188(8):510-7.
4. Masten AS. Ordinary magic. Resilience processes in development. Am Psychol 2001;56(3):227-38.
5. Nemeroff CB, Bremner JD, Foa EB, et al. Posttraumatic stress disorder: a state-of-the-science review. J Psychiatr Res 2006;40(1):1-21.
6. Park CL, Adler NE. Coping style as a predictor of health and well-being across the first year of medical school. Health Psychol 2003;22(6):627-31.
7. Muris P, Schmidt H, Lambrichs R, Meesters C. Protective and vulnerability factors of depression in normal adolescents. Behav Res Ther 2001;39(5):555-65.
8. Khoshaba DM, Maddi SR. Early experiences in hardiness development. Consulting Psychology Journal: Practice and Research 1999;51(2):106-16.
9. Rutter M. Resilience: some conceptual considerations. J Adolesc Health 1993;14(8):626-31,690-6.
10. Morgan CA, 3rd, Wang S, Southwick SM, et al. Plasma neuropeptide-Y concentrations in humans exposed to military survival training. Biol Psychiatry 2000;47(10):902-9.
11. Heilig M, Koob GF, Ekman R, Britton KT. Corticotropin-releasing factor and neuropeptide Y: role in emotional integration. Trends Neurosci 1994;17(2):80-5.
12. Foa EB, Rothbaum BO. Treating the trauma of rape: cognitive behavioral therapy for PTSD. New York: Guilford Press; 1998.
13. Foa EB, Dancu CV, Hembree EA, et al. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. J Consult Clin Psychol 1999;67(2):194-200.
14. Brosse AL, Sheets ES, Lett HS, Blumenthal JA. Exercise and the treatment of clinical depression in adults: recent findings and future directions. Sports Med 2002;32(12):741-60.
15. Singh NA, Clements KM, Singh MA. The efficacy of exercise as a long-term antidepressant in elderly subjects: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci 2001;56(8):M497-504.
16. Cotman CW, Berchtold NC. Exercise: a behavioral intervention to enhance brain health and plasticity. Trends Neurosci 2002;25(6):295-301.
17. Dishman RK, Berthoud HR, Booth FW, et al. Neurobiology of exercise. Obesity (Silver Spring) 2006;14(3):345-56.
18. Fredrickson BL. The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions. Am Psychol 2001;56(3):218-26.
19. Folkman S. Positive psychological states and coping with severe stress. Soc Sci Med 1997;45(8):1207-21.
20. Charney DS. Psychobiological mechanisms of resilience and vulnerability: implications for successful adaptation to extreme stress. Am J Psychiatry 2004;161(2):195-216.
21. Koenig HG, George LK, Peterson BL. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry 1998;155(4):536-42.
22. Rachman S. The concept of required helpfulness. Behav Res Ther 1979;17(1):1-6.
23. Southwick SM, Vythilingham M, Charney DS. The psychobiology of depression and resilience to stress: implications for prevention and treatment. Annual Review of Clinical Psychology 2005;1:255-91.
24. Resick PA. Clinical psychology: a modular course. Philadelphia: Taylor & Francis Group; 2001.
25. Rhodes JE, Roffman J, Grossman JB. The rhetoric and reality of youth mentoring. In: Rhodes JE, ed. New directions in youth development: theory, practice, and research—a critical view of youth mentoring. San Francisco: Jossey-Bass; 2002: 9-20.
26. Frankl VE. Man’s search for meaning. Boston: Beacon Press; 1959:75-7.
27. Ochsner KN, Ray RD, Cooper JC, et al. For better or for worse: neural systems supporting the cognitive down- and up-regulation of negative emotion. Neuroimage 2004;23(2):483-99.
1. Frans O, Rimmo PA, Aberg L, Fredrikson M. Trauma exposure and post-traumatic stress disorder in the general population. Acta Psychiatr Scand 2005;111(4):291-9.
2. Breslau N, Davis GC, Andreski P, Peterson E. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 1991;48(3):216-22.
3. Fauerbach JA, Lawrence JW, Schmidt CW, Jr, et al. Personality predictors of injury-related posttraumatic stress disorder. J Nerv Ment Dis 2000;188(8):510-7.
4. Masten AS. Ordinary magic. Resilience processes in development. Am Psychol 2001;56(3):227-38.
5. Nemeroff CB, Bremner JD, Foa EB, et al. Posttraumatic stress disorder: a state-of-the-science review. J Psychiatr Res 2006;40(1):1-21.
6. Park CL, Adler NE. Coping style as a predictor of health and well-being across the first year of medical school. Health Psychol 2003;22(6):627-31.
7. Muris P, Schmidt H, Lambrichs R, Meesters C. Protective and vulnerability factors of depression in normal adolescents. Behav Res Ther 2001;39(5):555-65.
8. Khoshaba DM, Maddi SR. Early experiences in hardiness development. Consulting Psychology Journal: Practice and Research 1999;51(2):106-16.
9. Rutter M. Resilience: some conceptual considerations. J Adolesc Health 1993;14(8):626-31,690-6.
10. Morgan CA, 3rd, Wang S, Southwick SM, et al. Plasma neuropeptide-Y concentrations in humans exposed to military survival training. Biol Psychiatry 2000;47(10):902-9.
11. Heilig M, Koob GF, Ekman R, Britton KT. Corticotropin-releasing factor and neuropeptide Y: role in emotional integration. Trends Neurosci 1994;17(2):80-5.
12. Foa EB, Rothbaum BO. Treating the trauma of rape: cognitive behavioral therapy for PTSD. New York: Guilford Press; 1998.
13. Foa EB, Dancu CV, Hembree EA, et al. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. J Consult Clin Psychol 1999;67(2):194-200.
14. Brosse AL, Sheets ES, Lett HS, Blumenthal JA. Exercise and the treatment of clinical depression in adults: recent findings and future directions. Sports Med 2002;32(12):741-60.
15. Singh NA, Clements KM, Singh MA. The efficacy of exercise as a long-term antidepressant in elderly subjects: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci 2001;56(8):M497-504.
16. Cotman CW, Berchtold NC. Exercise: a behavioral intervention to enhance brain health and plasticity. Trends Neurosci 2002;25(6):295-301.
17. Dishman RK, Berthoud HR, Booth FW, et al. Neurobiology of exercise. Obesity (Silver Spring) 2006;14(3):345-56.
18. Fredrickson BL. The role of positive emotions in positive psychology. The broaden-and-build theory of positive emotions. Am Psychol 2001;56(3):218-26.
19. Folkman S. Positive psychological states and coping with severe stress. Soc Sci Med 1997;45(8):1207-21.
20. Charney DS. Psychobiological mechanisms of resilience and vulnerability: implications for successful adaptation to extreme stress. Am J Psychiatry 2004;161(2):195-216.
21. Koenig HG, George LK, Peterson BL. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry 1998;155(4):536-42.
22. Rachman S. The concept of required helpfulness. Behav Res Ther 1979;17(1):1-6.
23. Southwick SM, Vythilingham M, Charney DS. The psychobiology of depression and resilience to stress: implications for prevention and treatment. Annual Review of Clinical Psychology 2005;1:255-91.
24. Resick PA. Clinical psychology: a modular course. Philadelphia: Taylor & Francis Group; 2001.
25. Rhodes JE, Roffman J, Grossman JB. The rhetoric and reality of youth mentoring. In: Rhodes JE, ed. New directions in youth development: theory, practice, and research—a critical view of youth mentoring. San Francisco: Jossey-Bass; 2002: 9-20.
26. Frankl VE. Man’s search for meaning. Boston: Beacon Press; 1959:75-7.
27. Ochsner KN, Ray RD, Cooper JC, et al. For better or for worse: neural systems supporting the cognitive down- and up-regulation of negative emotion. Neuroimage 2004;23(2):483-99.