“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one most adaptable to Change” – Charles Darwin

The vast majority of us are exposed to an event that falls under the psychological definition of “a major trauma” during our lifetime. This might be obvious (i.e. the death of a parent) but can also be an event that people don’t recognize as traumatic. Individuals deals with these traumas differently based on our genetics, our learned behaviors, and how much other stress we are under at that time. Physicians and scientists study this phenomenon under the umbrella term of “resilience.”

Although there is no universal consensus, the American Psychiatric Association defines resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of threat.” Resilience has been shown to lead to resistance against and quicker recovery from both physical or mental disease, making it arguably one of the most important aspects of preventative healthcare that we can help our patients develop.

Developing Resilience – Genetic and Environmental Factors

Some elements of mental and physical illness are purely genetic. Twin studies have shown that Post Traumatic Stress Disorder has a heritability of 32-38%, while depression is estimated to be 40-50% inherited. We also known that some specific alleles make us more susceptible to mental illness. One of the best-studied phenomenon of this is the short arm of the serotonin transporter gene. A single substitution of one of the base pairs of DNA transforms the way this receptor interacts in the amygdala-ventromedial prefrontal cortex and the dorsal raphe nucleus of the brain. Because of its association with depression, this gene has been termed a “Risk allele.”  

Genetics play a role in our birth, but the qualities that make-up resilience can also be changed by early childhood trauma. Contrary to popular wisdom, “that which does not kill us” does not necessarily make us stronger. In fact, it may have the opposite effect. Early traumas such as child abuse lead to an over activation of SNS and HPA pathways, increasing the susceptibility to anxiety, PTSD, and a rewiring of emotional processes that can last into adulthood. The list of hormones believed to play a role in regulating trauma continues to grow, including neuropeptide Y, the hypothalamic-pituitary-adrenal axis, noradrenaline, dopamine, and serotonin. Therefore, some people will have a harder time both avoiding inheriting chronic diseases (like depression) or also be more likely to develop mental diseases after major traumas without developing pathological conditions related to stress afterward. On the other hand, studies of maltreated children have shown that positive social support can help protect against the development of depression, even in children with the previously mentioned “risk allele.”

The environmental part of the equation

Environmental considerations and learned behavior also play a role in developing resilience. In longitudinal studies of teenagers admitted to psychiatric facilities, the following qualities were found to be crucial to resilience: Personal agency, self-reflection, and a commitment to relationships. These qualities are partially inherited, but can also be learned. Treatments like Cognitive Behavioral Therapy (CBT) have had success at incorporating “resilience protective factors” to counterbalance risk factors for mental illnesses such as depression. Some authors even speculate that these protective factors will occur naturally in life, as most research has shown older adults to be more stress resilient than younger individuals.  In sum, resilience is a multi-systemic process involving neuroregulatory pathways, emotional regulation, social skills, relationships, and physical health.

By its very nature, mental disease is susceptible to improvement by a changes in one’s mental processes or outlook, however these resilient qualities have also demonstrated positive effects in those suffering from physical disease.

Resilience and Physical Illness

Positive attitude, cognitive flexibility, and a strong moral compass also improve outcomes in both survivable and fatal chronic diseases. Studies of patients after Acute Coronary Syndrome (ACS) have found optimism to be associated with a faster recovery. Patient-assessed resilience scales also negatively correlate with troponin and myoglobin levels following ACS, implying an effect on the inflammatory pathway. Some personality traits associated with resilience have also shown to be positive in non-survivable diseases; an ability to maintain optimism has been associated with better quality of life following diagnosis in both low (breast) and high (gastric) mortality rate cancers., While we understand that resilience improves recovery, many facets of how this state of mind actually works remain a mystery.

One yet to be researched possibility for the power of resilience is the placebo effect. Beneficial effects attributable to a patient’s belief system have long been recognized and validated in the medical community. Optimistic, driven individuals are more likely to believe they will get better from either mental or physical illness, which may actually lead to physiological and psychological improvement of their disease. Resilient individuals, in a sense, may self-select for the placebo effect, and therein benefit from it. As physicians, we must continue to instill these virtues in our patients so that they may resist and improve from disease. Promoting a strong will, life purpose, and optimistic outlook amounts to a form of primary prevention, true to the teachings of Sir William Osler, who famously states: “The good physician treats the disease. The great physician treats the patient with the disease.”

About The Author

Ian Savage Elliott

Dr. Ian Savage Elliott is a Surgical Intern at Massachusetts General Hospital. He was educated at the Royal College of Surgeons in Ireland and Colgate University. His interests include tissue regeneration and minimally invasive surgery. Outside the hospital, he enjoys traveling as well as playing and coaching rugby. Any opinions expressed here are solely his own.