Earlier this year I read an outstanding book with the title above. A chapter from this book was the basis of my last blog on exercise and the reference for the book is given there. With this post, I wish to review some of the material presented in the introduction to that book and look at the question: "what is resilience?".
As with the term "stress", resilience is a term borrowed from the material sciences. And why not? Most of us in psychiatry have more than a little "physic's envy". Resilience refers to the property whereby materials return to their previous shape after being bent or stretched, i.e., stressed. Some materials have very little resilience and break upon being stressed while at the other end of the spectrum some materials return to the original configuration with their original properties, i.e., very resilient. There is another materials sciences term not mentioned in the book but alluded to in the many examples of perseverance that are cited and that is "tempered". This term is often used in referring to the manufacture of steel. If the steel is reheated and cooled after being cast it is said to be tempered. This improves the steel's elasticity and hardness. In this regard, I often think of someone such as Senator John McCain who endured a great deal of torture at the hands of the enemy as a war captive. Yet, he emerged from that episode tempered due to his resilience. I make this distinction to point out the difference between the two terms and their metaphorical validity. Resilience does not change the underlying properties of the material, it is the underlying properties that allow the material to be resilient. In tempering the material's properties are changed so that the resulting material is better suited for the purpose for which it is designed. The most commonly used metaphor for resilience is the green twig compared to the dry twig. The dry twig breaks from stress, the green twig bends, returns to it's previous shape and continues to grow. Perhaps we will in later posts return to this metaphor when discussing attachment to and interaction with our families, friends, and environment.
Now that we have our definition of terms out of the way, let's dig a little deeper into resilience not as a materials property but as a psycho-biologic property. Resilience is not any one specific thing but rather a property that is complex, multidimensional, and dynamic. When responding to stress a person may show greater competence in some areas of behavior and interactions than others and these competencies may be in flux over time. For example, a person experiencing difficult work relationship may become more competent in managing work related relationships but at the same time not show an increase in managing family relationships. In 2003 Conner and Davidson published a rating scale that is purported to measure resilience. This scale ranks 25 characteristics on a 0 to 5 scale (higher numeric ranking reflects greater competency in that particular characteristic). The 25 items are listed below.
1. Able to adapt to change
2. Close and secure relationships
3. Sometimes fate or God can help
4. Can deal with what ever comes
5. Past success gives confidence for new challenges
6. See the humorous side of things
7. Coping with stress strengthens
8. Tend to bounce back after illness or hardship
9. Things happen for a reason
10. Best effort no matter what
11. You can achieve your goals
12. When things look hopeless, I don't give up
13. Know where to turn for help
14. Under pressure, focus and think clearly
15. Prefer to take the lead in problem solving
16. Not easily discouraged by failure
17. Think of self as strong person
18. Make unpopular or difficult decisions
19. Can handle unpleasant feelings
20. Have to act on a hunch
21. Strong sense of purpose
22. In control of your life
23. I like challenges
24. You work to attain your goals
25. Pride in your achievements
If you are thinking that this list describes the qualities of Navy Seals or Army Rangers, you would be correct. Instructors for these courses are not necessarily looking for the absolute strongest or the absolute smartest young men (although these are qualities they seek) but rather they are looking for the most resilient. When you are in a tough situation you are looking for someone who will bend and not break, someone who will adapt and not stick to a rigid consistency.
This all begs the question, Is resiliency an innate quality of the individual or is it a learned group of behaviors? Perhaps the best we can say about this is that resilience is common but the achievement of resilience is easier for some than others. Almost everyone can learn to be more resilient, even if everyone cannot attain the resilience of a Navy Seal. All of us have the opportunity to mange stressful events in our everyday life, view adversity as a challenge to be managed and even use as a facilitator of personal growth, and practice making clear decisions under stressful situations. In a previous blog post I outlined the physiology of the stress response. In that post I pointed out that some stress in the acute situation is beneficial, but long term stress in harmful to any organism including humans. Let me quote the authors of Resilience. "Most of us have been taught to believe that stress is bad. We have learned to see stress as our enemy, something that we must avoid or reduce. But the truth is, when stress can be managed, it tends to be very good and even necessary for health and growth. Without it, the mind and body weaken. If we can learn to harness stress it can serve as a catalyst for developing greater strength and even greater wisdom."
Even though my practice is psychopharmacology I must admit that we do not have any medication to facilitate resilience. We have medications that will modify the stress response at a physiologic level but no medications that will give one the characteristics of resilience. However, developing resilient behaviors and attitudes may lead to requiring less medication to mitigate the stress response.
In the next few blog posts I will review some of the literature on ways to become more resilient.
1. Southwick, SM and Charney, DS. (2012) Resilience. The Science of Mastering Life's Greatest Challenges. Cambridge University Press.
2. Connor, KM and Davidson, JRT. (2003). Development of a new resilience scale: The Connor-Davidson resilience scale. Depression and Anxiety 18: 76-82.
The new year has arrived and with it our annual resolution, "that this will be the year that I get in shape and shed a few pounds." This is an admirable aspiration and even more admirable if carried out consistently over the new year. In the paragraphs below I wish to share with you the positive effects of a regular and challenging exercise routine.
Exercise Lowers The Risk of Cardiovascular Disease
Most of us take the above statement as a truism. Regular exercise is not only beneficial in lowering the risk of developing cardiovascular disease but also in managing cardiovascular disease that is already present. Exercise that raises one's heart rate to one's age adjusted target heart rate and keeps it there for 20 to 30 minutes sets into motion a number of physiological changes that over time lead to this reduction in heart disease. The forcful contraction of the heart muscle along with the increased blood flow and pressure in the peripheral arteries leads to a resetting of the autonomic nervous system. This leads to changes in the resting state such as a lower resting heart rate, lower blood pressure, and a more variable heart rate. These are all associated with a decreased risk of cardiovascular disease. In addition, this regular exercise decreases inflammation that is measured by blood borne markers such a C-reactive Protein (CRP) and IL-6. Inflammation is a critical component of the development of arterial plaque. The most significant changes in inflammatory markers are seen after 12 months of regualar exercise.
Exercise Lowers the Risk of Chronic Diseases
Regular exercise as described above has been associated with a reduction in:
- early death
- type II diabetes
- high blood pressure
- adverse lipid profile
- metabolic syndrome
- colon and breast cancer
When formally sedentary people begin an exercise program as described above and continued for a period of 6 months or more, their CRP levels dropped by about 30% or roughly the equivalent of the amount decreased by a statin drug. There was also modest evidence for lower rates of hip fractures and reduced bone density.
Exercise Helps Reduce the Symptoms of Depression
One study found that 16 weeks of aerobic exercise was as effective in reducing the symptoms of depression as treatement with the antidepressant Zoloft. Both groups had a greater than 60% response rate i.e., a 50% or greater reduction in baseline symptoms. The Zoloft group responded faster but the exercise group had a more enduring effect with less likelihood of relapse. Exercise reduces sadness and limits depressive symptoms even in people who are not suffering from major depression.
Exercise Helps Reduce Anxiety
Exercise not only helps reduce the symptoms associated with generalized anxiety disorder and panic disorder but also reduces symptoms in people with "anxiety-sensitivity". People with anxiety-sensitivity tend to over-interpret and catastrophize physical sensations such as a rapid heart beat, sweating, and rapid breathing. All of these occur during vigorous physical exercise. Over time the person exercising learns that these sensations are not life-threatening and the catastrophizing thoughts get extinguished.
Exercise Improves Brain Functioning and Cognition
Aerobic exercise improves cognitive functions such as attention, planning, decision making, inhibition, and memory. These improvements may be accomplished by increasing the size of the hippocampus, increasing the levels of BDNF and increaseing the volume of the prefrontal cortex,, among other changes. Exercise in midlife has been associated with a decreased risk of developing dementia and Alzheimer's disease. Exercise may slow age related memory decline.
Building Physical Fitness Habits
Now that you know the benefits of regular aerobic exercise, I am sure you are ready to get started on a regular regimen of physical training. The first question is what is an appropriate "dose" of exercise. In 2008 the Department of Health and Human Services recommended that on a weekly basis each person engage in: 2 hours and 30 minutes of moderate intensity exercise such a walking briskly (not strolling but walking with intensity and purpose), or 1 hour and 15 minutes of intense aerobic exercise such as jogging or swimming laps as well as 2 days of muscle strengthening exercises. Daily calisthenic routines for conditioning may be found by entering the search terms "Air Force 5BX" or "Army Daily Dozen". Drs. Southwick and Charney suggest that a physical fitness routine should incorporate the following elements:
1, Learn as much as you can about physical fitness and the benefits for your health.
2. If you have medical conditions or are concerned about the stress of exercise on your health, consult a physician before starting a vigorous exercise routine.
3. Try different exercise routines.
4. Set well-defined goals and monitor these goals to stay on task.
5. Consider using a trainer or coach. At the least, utilize and accountability partner.
6. Reward yourself as your goas are met.
7. Gradually increase the intensity of your cardiovasular and strength training. Remember, if it doesn't challenge you, it will not change you.
8. After each workout, allow your body to recover.
9. Practice healthy eating and sleep habits (more on this in a later blog). For the time being remember: YOU CAN'T EXERCISE YOUR WAY OUT OF BAD EATING HABITS.
10. Focus on the positive feelings associated with your exercise, e.g., increased energy, a "good" muscle soreness, better sleep.
11. Try to reach the point where being physically fit is an intergral part of your definition of yourself.
Southwick, SM, Charney, DS, Resilience, The Science of Mastering Life's Greatest Challenges. Cambridge Univerisity Press. 2012