Psychological Resilience - an overview (2023)

The Biology of Vulnerability and Resiliency in Older Adults

The biology that differentiates vulnerable or frail older adults from resilient or robust older adults is complex and multisystemic in nature. For example, diminished heart rate variability, which is a marker of dysregulated sympathetic nervous system activity, is associated with aging, frailty, and cardiac arrhythmias. Frail older adults have significantly higher levels of salivary cortisol during the afternoon nadir period, thereby suggesting chronically increased activity of the hypothalamic-pituitary-adrenal axis. Elevated levels of inflammatory cytokines, especially IL-6, tumor necrosis factor-α receptor 1 (TNFR1), and C-reactive protein, are strongly related to functional decline, frailty, chronic disease, and mortality in older adults, probably owing to increased fat, more senescent cells, and free radical production from altered mitochondria. IL-6 is likely to have a negative impact on stem cells and satellite cells, which in turn may contribute to the chronic anemia and age-related declines in skeletalmuscle (sarcopenia) and bone mass (osteopenia) commonly observed in frail, older adults. TNFR1 stimulates apoptosis and necroptosis, which are cell programs that lead to cell death and possibly tissue depletion and vulnerability later in life. In addition to stress response systems, endocrine factors that normally maintain muscle mass also play a role in frailty. For example, the adrenal androgen dehydroepiandrosterone sulfate and insulin-like growth factor 1 are significantly lower in frail adults. Future preventive or treatment strategies to reduce frailty and improve resiliency may target some of these stress responses or endocrinologic changes.

One approach is to measure physiologic parameters such as grip strength, walking speed, and weight loss, as well as to gather information about activity and fatigue levels. With use of this approach, the prevalence of frailty rises with increasing age; approximately 10% of community-dwelling adults older than 65 years meet these frailty criteria and subsequently are at increased risk of functional decline, falling, hospitalization, and death, even after adjustment for age, socioeconomic and smoking status, and multiple common disease states.

Frailty increases the likelihood for development of influenza or influenza-like illness in the 6 months after vaccination; the likelihood of requiring care in a skilled nursing or long-term care facility after hospitalization for general surgery; the likelihood of poor outcomes in patients with cardiovascular disease; poor renal transplant graft function and early hospital readmission after transplantation; falls, hospitalization, and mortality in patients on hemodialysis for chronic renal failure; and the risk of death in aging intravenous drug users. Biologic differences between frail and non-frail older adults (seeFig. 22-1) drive the marked vulnerability to adverse outcomes observed in the frail subjects.

Abstract

Psychological resilience, in general, and in particular when applied to suicidal experiences, lacks conceptual clarity. Here, we argue that psychological models of resilience to suicidal triggers and suicidal experiences must be grounded in the lived-experiences of experts-by-experience. There are, a least, five approaches to understanding resilience to suicidal experiences which should be systematically investigated. The dominant methodological approach is lacking in that it is simply uni-dimensional, i.e., represented by two poles of resilient and non-resilient; at risk and not at risk. More sophisticated models of psychological resilience to suicidal experience should be championed which span cultural, societal, and individual levels of understanding. Such approaches should be investigated using convergent qualitative, quantitative and mixed methods studies. In addition, more complex, diary study methods should be used creatively in this area. It is also important that approaches to understanding resilience to suicidality should be sensitive to issues experienced by mental health professionals.

Temporal Changes and Resilience of the Intestinal Microbiome

A healthy stable state is characterized by a diverse intestinal microbiota that develops from compositional and functional changes in the early years of life. There is such significant inter-personal variation, however, that a “healthy” state is difficult to define. Perhaps the best approximation for this definition would be one that promotes health by providing critical functions essential to the host.¹³ The concept of enterotypes based on metagenomics sequencing that stratifies healthy communities into 3 groups (Bacteroides,Prevotella, orRuminococcus) does not hold up when expanded to larger “healthy” populations where it becomes clear that the range of inter-personal variability is a continuous spectrum of stable configurations.¹³ The intestinal microbial ecosystem is generally stable over time, i.e., intestinal microbiota composition in samples obtained longitudinally from an individual is more similar to each other than to those obtained from a different individual. Thus although relative abundances of individual microbes can change, the overall community function and membership community remain intact. Similarly, an unfavorable microbial community can also be stable and contribute to chronic disease or states of poor health. Resilience is a key property of microbial community states, and is defined as the amount of stress or perturbation a microbial community can tolerate before it shifts to a different steady state (seeFig. 3.1). A high degree of resilience is desirable to maintain healthy states, but not in an unhealthy condition. The competition among microbes and positive and negative feedback to maintain levels of individual microbes further contributes to stability.¹³ Certain perturbations such as with short courses of antibiotics can result in a transiently disrupted microbial community structure (seeFig. 3.1), which often returns to the original state.¹⁴ A persistent perturbation such as long-term change in diet/antibiotic administration (seeFig. 3.1), or perturbation during a vulnerable phase such as early childhood or the peripartum period,^{15, 16} can result in disordered assembly with a shift to a disease-promoting state that is resistant to change.

Stress and resilience

Psychological resilience (hereinafter referred to as resilience) refers to a range of individual (e.g., optimism, adaptive coping skills) and environmental level resources (e.g., social support, community integration) that are associated with adaptation, or the ability to “bounce back” or quickly recover after adverse or stressful events (Bonanno, 2004; Campbell-Sills & Stein, 2007). Although the operationalization of resilience has proved to be difficult given the multidimensional nature of the construct, resilience has most recently been conceptualized as a process that may vary based on context or over the developmental lifespan. In the context of aging, resilience has been defined as both the ability to recover and the capacity to maintain functioning in the aftermath of adversity (Ryff, Singer, Love, & Essex, 1998). Such responses stand in contrast to the concept of vulnerability, which is broadly defined as the reduced ability to cope with stressors. Although early work on resilience primarily focused on adverse events during early childhood (Cicchetti, 2010), a burgeoning body of literature has focused on resilience in older adult populations.

Converging evidence suggests resilience may be related to better psychiatric and physiological outcomes in stress-exposed older adults. Indeed, a number of cross-sectional findings have demonstrated that composite measures of resilience and measures of individual resilience factors (e.g., mindfulness, perceived control, optimism) are associated with better adjustment to daily and chronic stress (Bretherton & McLean, 2015; de Frias & Whyne, 2015; Fang, Vincent, & Calabrese, 2015; Pietrzak & Cook, 2013; Puig-Perez, Hackett, Salvador, & Steptoe, 2017). For instance, in a sample of older adults living with HIV/AIDS, resilience factors (i.e., coping self-efficacy, hope/optimism, active coping, and social support) explained the relationship between stress and physical, emotional, and functional well-being (Fang et al., 2015). However, most of the research on stress, resilience, and well-being is cross-sectional, and thus longitudinal studies are needed to explore this relationship across the lifespan.

Factors associated with resilience have also been implicated in the relationship between stress and well-being in older adults. For instance, in recent years, optimism, long thought to confer protection against stress in younger adults, has been investigated in older adult cohorts. Several studies suggest optimism contributes to well-being in older adults exposed to stress. In a study of older adults with type 2 diabetes, lower levels of self-reported optimism (Scheier, Carver, & Bridges, 1994) were associated with a reduced cardiovascular response in response to a laboratory stress condition, whereas individuals with higher levels of optimism had a cardiovascular response similar to healthy adults (Puig-Perez et al., 2017). Importantly, higher levels of optimism have also been related to greater reported mental and physical health in healthy older adults and those with chronic health conditions (Bretherton & McLean, 2015; Kepka, Baumann, & Anota, 2013; Puig-Perez et al., 2017). Other factors have also been linked to resilience in older adults. In a review on resilience in older adults in Brazilian and international samples, psychological resources (e.g., self-esteem, sense of meaning, flexibility, social support) and emotional regulation (e.g., positive emotions regarding aging, self-control) emerged as common components of resilience (Fontes & Neri, 2015). Taken together, these findings suggest a range of individual and environmental factors may contribute to well-being in diverse older adult populations.

Additional resilience factors may also explain differences in well-being amongst older adults living with chronic health conditions (Fang et al., 2015) or acting as caregivers for relatives with chronic illnesses (Mausbach, Aschbacher, & Patterson, 2006; Mausbach et al., 2010). In particular, adaptive coping strategies (e.g., actively working to solve problems) appear to relate to better outcomes in comparison to escape avoidance coping (e.g., hoping that problems disappear) amongst older adults exposed to stress. For instance, in spousal caregivers of individuals with AD, avoidance coping was related to greater depressive symptoms (Mausbach, Roepke, & Chattillion, 2012). Alternatively, problem-focused or approach coping strategies have been associated with better outcomes, including increased levels of QoL and lower mood symptoms, in older adult caregivers (Roche, Croot, MacCann, Cramer, & Diehl-Schmid, 2015). These findings suggest that enhancing adaptive coping strategies may enhance well-being and protect against stress-related disorders in older adults facing chronic stressors.

Although fewer studies have investigated the temporal relationship between resilience factors and exposure to stress, a number of preliminary findings suggest resilience factors (e.g., mastery, positive coping strategies, planning ahead) may reduce the likelihood of stress-related health conditions (Bei et al., 2013; Bookwala, 2014; Kahana, Kelley-Moore, & Kahana, 2012). Findings from these studies lend support to ongoing research on interventions to promote resilience in stress-exposed aging adults (Alschuler, Arewasikporn, Nelson, Molton, & Ehde, 2018; Fullen & Gorby, 2016; Smith & Hanni, 2017).

Unifying Concepts: The Transactional Model, Risk, and Resilience

Thetransactional model proposes that a child's status at any point in time is a function of the interaction between biologic and social influences. The influences are bidirectional: biologic factors, such as temperament and health status, both affect the child-rearing environment and are affected by it. A premature infant may cry little and sleep for long periods; the infant's depressed parent may welcome this behavior, setting up a cycle that leads to poor nutrition and inadequate growth. The child's failure to thrive may reinforce the parent's sense of failure as a parent. At a later stage, impulsivity and inattention associated with early, prolonged undernutrition may lead to aggressive behavior. The cause of the aggression in this case is not the prematurity, the undernutrition, or the maternal depression, but the interaction of all these factors (Fig. 18.3). Conversely, children with biologic risk factors may nevertheless do well developmentally if the child-rearing environment is supportive. Premature infants with electroencephalographic evidence of neurologic immaturity may be at increased risk for cognitive delay. This risk may only be realized when the quality of parent–child interaction is poor. When parent–child interactions are optimal, prematurity carries a reduced risk of developmental disability.

An estimate of developmental risk can begin with risk factors, such as low income, limited parental education, and lack of neighborhood resources. Stress and anxiety in pregnancy are associated with cognitive, behavioral, and emotional problems in the child. Early stress may have effects on aging mediated by shortening of telomere length, a link to health disparities. Risk for negative outcomes over time increases exponentially as a result of declining plasticity and accumulation of risk factors (both behavioral and environmental). Interventions are most effective in young children; over time, risk increases as the ability to change decreases.

Children growing up in poverty experience multiple levels of developmental risk: increased exposure to biologic risk factors, such as environmental lead and undernutrition; lack of stimulation in the home; and decreased access to interventional education and therapeutic experiences. As they respond by withdrawal or acting out, they further discourage positive stimulation from those around them. Children of adolescent mothers are also at risk. When early intervention programs provide timely, intensive, comprehensive, and prolonged services, at-risk children show marked and sustained upswings in their developmental trajectory. Early identification of children at developmental risk, along with early intervention to support parenting, is critically important.

Children can have appropriate developmental trajectories despite childhood trauma.Resilience is the ability to withstand, adapt to, and recover from adversities. There are several resilience factors that can be modified: a positive appraisal or outlook and good executive functioning (seeChapter 48); nurturing parenting (seeChapter 19); good maternal mental health, good self-care skills, and consistent household routines; and an understanding of trauma. The personal histories of children who overcome poverty often include at least one trusted adult (parent, grandparent, teacher) with whom the child has a special, supportive, close relationship. Pediatric providers are positioned to target and bolster resilience in their patients and families.

Introduction

Life course perspectives on adult development and aging face the formidable challenge of accounting for not only population-wide normative differences and group change but also the underlying wide variation in individualized trajectories and outcomes in neurological, psychological, and physical health. Theories of aging succeed to the extent that they advance the description and explanation of differential trajectory patterns (e.g., extended stability, exacerbated decline), their associations with long-term aging outcomes (e.g., dementia), and predictors and mechanisms of both (Dixon, 2011). Among the more complex and challenging of aging phenomena are those in which individuals experiencing adverse circumstances (e.g., elevated genetic risk for Alzheimer’s disease) still thrive or at least avoid or delay decline or illness and maintain normal or higher levels of functioning. The concept of resilience is increasingly recognized as an important phenomenon in aging (Aléx, 2010; Bauman, Adams, & Waldo, 2001; Bolton, Praetorius, & Smith-Osborne, 2016) as it is necessary to describe trajectories of aging whereby individuals overcome challenges or do not decline despite having substantial endogenous or exogenous stressors or risk factors. The large range of definitions of resilience and the absence of clear consensus of approaches to this topic present challenges for reviewing and synthesizing the associated literature (Luthar & Brown, 2007).

In both applied and theoretical research, resilience has been examined within the mental, cognitive, and physical health domains, using multiple definitions and methodologies, and examining a variety of contexts and predictors (Zannas & West, 2014). This chapter provides an overview of the key concepts, methodological issues, and content areas of resilience research in the field of adult development and aging. It focuses on resilience of individuals, not of social groups or institutions, although these are interdependent (Boon, Cottrell, King, Stevenson, & Millar, 2012).

2.3 Cultural factors at the intersection of race and SES

Cultural beliefs and models can also shape developmental contexts. For example, cultural values may operate as protective or compensatory factors in low-SES families of color (Gaylord-Harden, Burrow, & Cunningham, 2012). Studies have found that familism supported psychological resilience and higher-quality parenting among Mexican-origin families living in more disadvantaged circumstances (White, Liu, Nair, & Tein, 2015; White, Roosa, & Zeiders, 2012). Meanwhile, cultural assets, such as spiritual and religious beliefs among African Americans, may likewise foster better family functioning (Dunbar, Leerkes, Coard, Supple, & Calkins, 2017) or promote healthy development (Brega & Coleman, 1999; Butler-Barnes, Williams, & Chavous, 2012; Gaylord-Harden et al., 2012). Culturally-adaptive childrearing practices may also interact synergistically with structural factors to buoy resilience or exacerbate vulnerability. For example, Banerjee, Rowley, and Johnson (2015), recently found that, in violent neighborhoods, ethnic-racial socialization practices intended to instill cultural pride were associated with less depression, whereas parental messages meant to raise awareness about discrimination were tied to heightened depressive symptomatology.

Cultural perspectives on the macrostructural context can also influence socialization goals and practices and thus youth outcomes, such as identity development. Less-stigmatized racial/ethnic minority families, for instance, may endorse cultural perspectives focused on the abundance of opportunities they and their children enjoy in America. At the same time, some racial/ethnic groups may perceive particular status-based obstacles (e.g., immigrant and generational status, English-language proficiency) as temporary obstacles rather than systemic barriers to overcome (Arthur, 2000; Ogbu & Simons, 1998). Involuntary minorities (e.g., African American descendants of enslaved people, Native Americans), whose collective experience in America involves pervasive subjugation (e.g., slavery, Jim Crow segregation, colonization) due to systemic racism, might be more suspicious of societal institutions (Ogbu & Simons, 1998). Conversely, voluntary minorities (i.e., immigrants of color), may not view their adopted society through the same prism of suspicion and distrust because they have not been subject to the same history of oppression and exploitation in the U.S. context (Greer, 2013; Ogbu & Simons, 1998). Additionally, to the extent that immigrants of color subscribe to the notion that America is the land of opportunity and internalize negative stereotypes about the intellectual or moral inferiority of low-status subpopulations in the United States, they might hold negative attitudes toward their more stigmatized peers of color (Arthur, 2000; Greer, 2013; Waters, 1994).

Indeed, increasing research suggests that some racial/ethnic subgroups, including both Asian and Black ethnics, perceive themselves to occupy an “elevated minority status” in comparison to their African American counterparts (Greer, 2013). Drawing from in-depth interviews, Dhingra (2003) found that many second-generation Asian American respondents made a distinction between cultural and racial/ethnic minority status. They did not perceive themselves to be cultural minorities and believed their more advantaged economic status, higher educational attainment, and greater acculturation distinguished them from native-born Black Americans (Dhingra, 2003). Equivalent attitudes were expressed by first- and second-generation immigrant Black parents and adolescents who endorsed strong ethnic (i.e., West Indian, Haitian) identities (Waters, 1994). To understand these findings, it is important to remember that many immigrant-origin Asian and Black Americans represent a hyper-selected group who have achieved high occupational status and educational attainment levels in their countries of origin (Zhou & Lee, 2017). These advantages may influence their rates of upward mobility, perceptions of the opportunity structure, and general attitudes toward African Americans, who tend to be disproportionately disadvantaged in America.

Notably, variation in cultural practices, values, and beliefs can impact psychological well-being (Wang, Henry, Smith, Huguley, & Guo, 2019). In a recent meta-analysis, Yoon et al. (2013) observed that greater acculturation (i.e., assimilation to mainstream norms and culture) was associated with better mental health for Asians, whereas enculturation (i.e., strong affinity for or belief in the centrality of one's racial/ethnic subculture) was more strongly related to enhanced psychological health among African Americans. Using qualitative data from a sample of parents of preschool-aged children, Anderson, Jackson, et al. (2015) discovered parents of color often communicated messages meant to enhance cultural pride and knowledge. However, they also found that African Americans were more likely to convey information aimed at increasing their children's awareness of discrimination and cultivating coping strategies to counteract it; thus, ethnic-racial socialization played a key role in how they supported their children's school readiness. In contrast, immigrant-origin Korean Americans tended to avoid messages about discrimination and bias. Instead, Korean-origin parents often expressed the belief that individual achievement and meritorious behavior would essentially allow their children to escape or counteract any existing discrimination and prejudice.

Definition and Background

Resilience can be defined as “protective factors which modify, ameliorate, or alter a person’s response to some environmental hazard that predisposes to a maladaptive outcome” (Rutter, 1987, p. 316). Although some authors argue that resilience should be seen as a dynamic process rather than a stable trait (Windle, Bennett, & Noyes, 2011), alternative research has classed resilience as a trait (Block & Block, 1980; Connor & Davidson, 2003). The construct of psychological resilience has been studied to further understand why some individuals cope with or even flourish in stressful or pressurized situations (Fletcher & Sarkar, 2013). Resilience can stem from adverse life events, such as parental loss, and cause negative effects on well-being (Seery, 2011). However, the emerging concept that resilience develops through adversity (Seery, 2011) is one that has filtered through to the performance context. In this context, individuals face a variety of stressors and importantly, in some instances, that is, sport, the individuals actively put themselves in these stressful situations and are forced to develop this quality (Fletcher & Sarkar, 2012). Resilience can be developed through negative sporting experiences, such as failure (Fletcher & Sarkar, 2012; Turner & Barker, 2013), which then fosters the ability to bounce back from negative experiences (Fletcher & Sarkar, 2013), such as stress. The construct influences the stress process throughout, not only on the initial appraisal of stress, but also on the selection of coping strategies (Fletcher & Sarkar, 2013).

4.1 Resilience brain markers

Neuroimaging research supports the existence of specific brain correlates associated with resilience in youth with a family history of AUD. Comparing resilient (non-drinkers) to vulnerable (hazardous drinkers, Table 1) emerging adults (18–25 year-olds) of AUD parents, cross-sectional results showed that the vulnerable group reported emotional distress, risky substance use, and greater activity in the middle frontal gyrus when rating negative emotional pictures compared with their resilient counterparts and showed higher activation of the posterior cingulate cortex during a working memory challenge (Brown-Rice et al., 2018). In another cross-sectional study, blunted nucleus accumbens responsivity was observed during decision-making in FHP participants who did not present alcohol use problems, suggesting that this attenuated activity is protective (Yau et al., 2012).

A longitudinal study assessed self-reported psychological resilience in early adolescence (12–15 years old) and related it to measures taken in late adolescence (Weiland et al., 2012). Greater resilience was predictive of lower substance use, fewer alcohol-related problems, and better executive performance. Associations also emerged between resilience and subthalamic nucleus and pallidum activation detected with fMRI during a working memory task. Moreover, compared with a low resilience group, youth with high resilience had stronger functional connectivity between the subthalamic nucleus and median cingulate cortex (Weiland et al., 2012). In the same cohort, psychological resilience in adolescents with a family history of AUD and carriers of the G allele (GABRA2) was associated with lower activation in the inferior parietal cortex during emotional processing and less severe externalizing behaviors (Trucco, Cope, Burmeister, Zucker, & Heitzeg, 2018); however, which resilience factor exerted the greatest influence remains unknown.

Several studies also directly compared resilient and vulnerable youth with prospective evaluations, for which follow-up was conducted after the onset of hazardous drinking or substance use in vulnerable youth. The relevance of functional connectivity between frontal and striatal brain networks (dorsolateral prefrontal cortex and posterior cingulate) was found, such that resilient youth (11–16 years old) had greater functional connectivity between the left dorsolateral prefrontal cortex and the left posterior cingulate cortex than vulnerable youth before the onset of excessive drinking (Martz et al., 2019). These two networks were also explored separately by evaluating brain responses during executive control and reward processing (adolescents from 12 to 14 years old at baseline). Greater activation in the right dorsolateral prefrontal cortex during correct inhibition was a significant predictor of resilience, whereas neural activation in the ventral striatum (nucleus accumbens) was not a significant predictor of resilience (Martz, Zucker, Schulenberg, & Heitzeg, 2018). Functional brain responses were also evaluated during passive viewing of emotional words (positive, negative, or neutral). Resilient adolescents (11–17 years old) had greater activation in bilateral orbital frontal gyrus and left insula in response to emotional stimuli, whereas vulnerable ones showed higher activation of the dorsomedial prefrontal cortex and lower activation of the ventral striatum and the amygdala bilaterally. The vulnerable group also had more externalizing symptoms, such as aggressive and delinquent behaviors, than the resilient group (Heitzeg, Nigg, Yau, Zubieta, & Zucker, 2008).

Felitti et al. (1998)

Another major focus of researchers has been to unravel the role that “neurological soft signs” (see below) play in the development of PTSD. The initial review of vulnerability to PTSD is the association with these structural abnormalities.

It seems as though it should be easy to clarify and decisively conclude the psysiological and psychological consequences of acute and chronic stress. It is understood that the stress mechanisms that impact the autonomic nervous system and adrenocortico system offer a benefit when it is a short-term response (protective), but can damage and accelerate the disease process when activated over a long period of time (vulnerability). In other words, the concern is that altered states of brain chemistry and function result in an increased susceptibility to the vulnerable impact of stress hormones. These considerations are important to a conceptual understanding of the connection between stress and health in terms of life experiences, health behaviors, choices of thought/interpretation of experience, genetics, and socio-economic factors.

In addition, the outcome has remained ambiguous because the chemical mediators of stress vary in their basal secretion according to diurnal rhythm that is coordinated by the light–dark cycle and sleep–wake cycle. Perturbances in the diurnal cycles are associated with pathophysiological outcomes and these issues make it difficult to discern with distinction aspects of temporal patterns and intensity that discriminate between vulnerability and resilience factors.