Digging deeper: Biological Resilience part 1

In my last post, I gave an overview of the "Four Domain" model of resilience.  The next several posts will explore each of these domains further and provide some guidelines to how you might go about "building up," your resilience in each of these areas (at least according to the model).

The first domain, the biological, I defined as "the ways our physical body deals with the stress of life."  Though it sounds pretty simple on the surface, there are books and books written about this stuff.  Let's take a bottom up perspective and start with the smallest parts of this: molecules!

Our body is a huge bio-chemical factory!  Everything from the hair on our heads to the hormones in our veins has been manufactured by the brilliant cells of our body.  Tiny signals, both inside and outside our cells, provide information that influence what kinds of other chemicals our body makes, in what quantity it makes them and what our cells themselves should do (grow, shrink, move, change shape...etc.).  

For example, if you scrape your knee while chasing after your dog, Tiger, on a long run by the beach near your home, the injured cells around the scrape release tons and tons molecules that all do things to ultimately 
help your knee heal.  One of these chemicals, arachidonic acid (AA) tells the nerves around the scrape (and ultimately your conscious mind) that there is something painful that has happened and you should probably take a look at your knee before resuming your chase.   Another one of these chemicals, serotonin, is released by the platelets nearest to the cuts in your knee, encouraging other nearby platelets to clump up and form a clot to prevent too much bleeding.  A third chemical, IL-6, tells your immune system to rev-up and be on guard, making sure that any virus, bacteria, fungus or parasite living on the sand in your scrape get identified and quarantined.   This all happens without us thinking about it at all and its just one of the myriad things our body does naturally.  

Amazingly, there are ways that you can make your body more resilient (or more vulnerable) to a knee scrape, a cold or a more complex stressor.  How?  By modifying your baseline chemical balance before and after the stressor.   How do we do that?  

Arachidonic Acid

Let's dive into this next week!

-B

p.s.  For those of you who want a sneak peak, here's a link to an article I like about inflammation and a link to the website of one of my favorite authors on food and brain health.

The Four Domain Model of Resilience

When I work with patients, I do a lot of the typical things that psychiatrists do:  I ask a lot of questions and I listen really hard to find out what's going on.  However, as you may have gathered from my last post, when I ask and listen, I'm also doing so with the goal of trying to understand what kinds of things are already working for the person sitting across from me.

Using a model developed by Dr. Nathaniel Laor, I look for specific strengths that fall within one or more of the four "Domains of Resilience."    By using this model, I am better able to map out where a person is thriving in addition to getting a direction for where and how to intervene.  Intervention can be as simple as supporting and encouraging a person to continue doing what they're already doing or helping them to develop new skill sets that may help them better address their concerns.

Here are the four "Domains" as I have interpreted them:

1) Biological - Simply put, this domain contains all of the ways our physical body deals with the stress of life.  It includes a huge range of factors that can be as small as the tiny molecules of inflammation that our body creates to deal with environmental and emotional toxins, or as big as the variability of our heart rate that reflects how easily our body relaxes after stress.  Though not easy to see on the outside, I can often get a sense of what a person's state of resilience is in this domain by asking about their diet, their exercise routine, whether they have any mindfulness practices and even how long they sit during a normal work day.  Interestingly, all of the other domains of resilience are ultimately translated back into the biological.  This means that people who are able to cultivate other kinds of internal strength can boost their biological resilience as well.

2) Psychological - How do we relate to ourselves?  The mind can be a powerful ally for helping us deal with the stressors we encounter in our daily lives.  The way we take in information, process the meaning of what we experience, express to ourselves and others what we think and feel, and behave in response to these thoughts and feelings says a lot about how well we are able to deal with stress.  Do you filter out certain types of information without knowing it?  Do you see new things as threats or as challenges?  How well do you understand the way your mind works?  Do you think positively about yourself?  The answers to these questions say a lot about how well a person is able to deal with the stressors of life.

3) Interpersonal - How do we relate with others?  We live in a world filled with other beautiful and complicated human beings.  How well we create, nourish, draw strength from and, if necessary, end relationships with others is one of the most important and
central tasks of living.  In times of ease, these relationships add richness and joy to our lives.  In times of stress, the stability and support of relationships can get us through hard times with a whole lot less wear and tear.  As relationships are so common, one would think that we'd be pretty good at negotiating the ins-and-outs of being in one.  Not so surprisingly, this is rarely if ever the case.  Given how fundamental relationships are to our lives, figuring out how to build and sustain a strong network of people we trust and who trust us is one of the most powerful resilience factors we have.

4) Transcendent - Why are you here?  I don't mean reading my blog (though if you're enjoying it, please let me know what you think), but here in this world.  That's a very big question, but by asking yourself and taking some time to answer that question, you can have a pretty powerful impact on how well you deal with whatever else may come your way.  Some of the healthiest folk I've worked with over the years were able to overcome what seemed to be insurmountable challenges and hardships through an awareness that their lives had a greater purpose.  They found this awareness in a number of areas, though most commonly through faith, through a commitment to service to the world and through creativity.

Please let me know what you think in the comments section.

-B

A comment I received suggested that I explain the differences between the traditional approach to medical treatment and what I am proposing through a resilience approach to psychiatry.

In the traditional model, a person comes to their physician with a problem. Through questions and diagnostic tools used to identify symptoms, signs and other markers for the illness, the physician makes a diagnosis based on an understanding of the reasons why such a problem would exist. Based on this diagnosis, the physician prescribes a medication with the goal of treating or palliating the problem. At some point in the future, the physician would reassess the patient to see if his or her symptoms had abated, and if not, revise their diagnosis and treatment until cure or adequate palliation.

In resilience health, there are two possible avenues to enter the system. In the first path, a person would approach the doctor similar to the way they might above, with a problem. In this pathway, the doctor would assess, diagnose and treat the problem in a similar way as the physician above might, but would also assess unique individual capacities, strengths and vulnerabilities and with the persons' participation, act as a guide to promote what the person is already doing well and make suggestions about modifying risk factors. This is actually what should be going on in most doctors appointments, but due to time constraints, the strength/vulnerability part is often boiled down to an assessment of problematic behaviors (drinking, drugs, smoking, dietary no-no's, sedentary habits, risky sexual behavior, sun block, seat belt use and helmet use).

The second entry point would be more of a yearly check-up/tune-up. I want to save this approach for later so I can spend a whole post outlining what this might look like.

I think the best way to demonstrate differences would be to describe two different kinds of psychiatric visits I've performed.

Traditional/typical approach:

I saw a middle aged female patient at a community clinic last week who had been given a diagnosis of bipolar disorder. After exchanging smiles and hand shakes, I asked what I could do to help. She said that she was there for a prescription and that her life, though stressful at times, was going well. I asked a little more about that and she offered that she had been having some troubles with her children who were taking advantage of her generosity and hadn't been looking for jobs as they told her they would. I asked her about how this had affected her, and she said that she was sleeping less well, and had been eating less for the past two weeks. I asked her if her mood had changed, or she had any symptoms relating to her bipolar diagnosis and she told me that she had been a little more irritable. Even so, she told me that the medication was keeping her "steady" and that she didn't make any changes to the medication regimen that she had been using for the past four years. I asked her if she wanted to see anyone to talk about her stress. She said she was fine, and that she would be talking to her case manager later in the day. I asked if she had been having any side effects from the medications. She denied any. I assessed for suicidality or homicidality, and she denied both. I wrote her scripts and suggested that we meet again in two months. She smiled, I smiled and she left the office.

Resilience approach:

I saw a younger male patient the other day who had been given a diagnosis of generalized anxiety disorder. I invited him into my office, smiled and shook hands.  I asked him how he was doing. Being new to me, he provided a short explanation of the course of his illness, including where he thought things began and where he was right now regarding his symptoms. In his narrative, he told me about his love of music and performance, and how his anxiety had impacted his ability to play instruments, making him sick before shows, with horrible nausea, sweaty palms, dry mouth and a feeling like his stomach was on fire. I heard that he had suffered a great deal due to his condition, but that he was making the best of his situation. He did this by making furtive half statements like "I think things are more under control now," or "I've been working hard on that and its been a little better." I asked him what he was doing to get things "under control" and he said that, before performing he told himself that his acute anxiety would pass once he got into it (reflection), and that he "pepped" himself up before going on stage saying things like "I can do this! This is going to be fun! I love stuff like this." (reappraisal) He then looked at me and said, "no one can tell I'm scared out of my mind... I guess my natural vibrato hides the shakiness of my voice ok." (humor). I asked him if he had learned anything else that could help him and he said that his father had used beer, but that he knew better than that.

I smiled at him, and told him how much I admired his strength, and determination to overcome his fears and symptoms. I explained how the body reacts to stress using the "fight-or-flight" system and how his reactions were on the high end of the normal spectrum. I also reflected with him that it seemed as though the repeated activation of his stress system was wearing away at his reserve. I named the skills he had been using to control his anxiety (reflection, reappraisal and humor), explaining how each of them work and suggesting slight modifications that might help. I affirmed that his hope for feeling better was well founded, and that through working together, he could get a handle on how he felt. I shared my thoughts that his anxiety was part of his family's psychiatric history, and that there were better, and safer tools than beer which he could use to overcome it. After answering a few of his questions, I provided him with scripts for medications he was taking and suggested a Beta Blocker for performance anxiety. He explained that the previous doctor he had seen had suggested this too, but he had refused, worried that he would get addicted to them. We spoke about the risks and the benefits, and he was exited that they might help him before an upcoming performance. We shook hands and he said "this was the best doctors appointment I have ever had." I smiled and told him how much I admired his strength.  We planned a meeting in two weeks to see how things were going.


Hope this helps!

Before we go any further with this idea, it might be important to define what resilience actually is.

As is the case with many words in the medical literature, resilience has too many meanings and consequently, it can be a bit confusing.

When defined by the basic sciences, resilience is used to describe how well a material can return the energy that is put into it. In other words, it is a measurement of how well an object can return to its original state after it has been stretched -- how springy is a spring. 

When used in biology, it takes on additional meanings. In cell biology it refers to the ability of a cell or a community of cells to recover from a disruption introduced into their environment. This can be extrapolated to other living communities. For example, we're currently very concerned about the resilience of fragile ecosystems as they are confronted by global climate change.  Will these plants and animals be able to adapt and "be resilient" to the changing environment?

When talking about human beings the word resilience takes on a lot of not-so-clear definitions. As it relates to the individual, a topic that I'll try to explain in the next few paragraphs, we talk about psychological resilience, familial resilience, community resilience (i.e. how well did New York recover after September 11th), physical/sports resilience (how quickly does Kurt Cousin's confidence recover after throwing an interception) and organizational resilience (how well does a business adapt to changes in the regulatory environment). For the purpose of this blog, I'll stick to psychological resilience. 

The definition of psychological resilience is not so straight forward either. The term has become a topic of research in three major areas of medicine:

1. Trauma and disaster intervention
2. At risk youth and decision making
3. The effect of medical illnesses (i.e. cancer) on mental well being 

Each research domain defines resilience slightly differently based on unique research methodology considerations. Even so, there are similarities that I'd like to touch on for the rest of this post.




First, in all three of the instances above, resilience is multifaceted. This definition characterizes a unique interplay between an individual's psychological, physiological and psycho-social state, their previous encounters with environmental challenges (their perception of the event) and vulnerabilities that come into play at the moment when a stressor is introduced. A schematic of this interplay is shown above. This particular image forms one of the theoretical foundations for clinical liaison psychiatry and includes within it something called "Allostasis" that I'll address in the future.

Second, resilience is considered to be a complex, dynamic process that can change from minute to minute. This is very different from other definitions where the resilience of a system is more or less static. Imagine a person, Frank, who is a first responder to a traffic accident. Within moments of seeing the accident happen, Frank has a complex interplay of emotions, physiological reactions and thoughts that would emerge predicting whether he would run to help the people in the accident or run away. 

Now imagine that the person who was in the accident was Frank's friend, or that he was standing next to his favorite teacher who happened to be a very calm person, or that he had special training in responding to traffic accident emergencies. This would potentially create a different response to the stressor and possibly a different psychological outcome in the end. One of the best examples of this comes from literature emerging from cancer psychiatry in children. The best predictor for how well a child does in the face of illness has to do with their parents' proximity and response to their condition. More on this later.

Third, in any given situation, resilience is a recursive process, where over the course of the effect of the stressor, a person has the ability to learn and adapt or become more vulnerable. If Frank were to run away from the accident, he would feel guilty, and potentially even more stressed than if he had gone to help. Alternatively, if he had gone to help and overcome the emotional, physiological and psychological barriers to him doing so, he would, in that moment, begin a process where he potentially felt stronger and more resilient in that moment.

Finally, and most importantly for this blog, resilience is something that can be actively modified prior to, during and following a stressful event. There are things that any person can learn to do that will help him or her cope better with stress and rebound more successfully. Many of these factors are learned throughout life; self-talk, suppression, humor, and mindfulness are a few skills that seem to emerge from cultural wisdom and neurobiology.

There are skills that can be honed and techniques that can be practiced that can help people deal with the daily (or more severe) stresses in their lives.

In clinical practice today, mental health practitioners begin with the assumption that all mental illness begins with pathology and is cured through discovering and fixing what's wrong. Patients, perhaps sensing this, arrive at their doctors appointments with questions based on this assumption: why do I feel like this? Why can’t I get what I want out of life? Why am I so sick and how can you help me?

As a culture, we have a tendency to dwell on our weaknesses with the thought that through sharpening our understanding of the things that contribute to the problem, we will find the solutions. This is and has been a very useful approach for fixing most simple and many complex problems in medicine -- it gives us a way of understanding where dysfunction occurs, provides a tool for analyzing these dysfunctions, presents a way of categorizing and naming things and inspires a methodology for returning the human being to a state of non-dysfunction.

Unfortunately, by using only this approach to address the causes of human suffering, we are left with incomplete solutions at best and potentially harmful ones at worst. Though we have made significant advances in our understanding of the way the brain works, the simple explanations psychiatrists have used to understand and explain mental illness (i.e. depression is caused by a chemical imbalance) are not proven fact, and new discoveries change these frequently. Consequently, the treatment we provide often leave both patient and practitioner frustrated with the results. Through this model, we try to correct what’s wrong without recognizing just how right things are already. We stand on our mountain peaks and look out over our failures, not recognizing just how far we’ve come, what we’ve overcome and how strong we actually are.

A different way of looking at mental health is through a resilience based approach or one that examines the strengths and capacities that appear both inherently in the developing human being and which we have learned explicitly through our exploration of science, spirituality and philosophy. This model is based on the assumption that human beings are fundamentally whole, and through the recognition and cultivation of certain traits, skills and capacities, we can live happier, more productive and more meaningful lives.

This is by no means a new idea. Not only has it existed in various forms throughout history, but it is being studied by scientists and doctors today. Even so, though a resilience based approach has gained some popular acceptance, its principles and wisdom has barely made a dent on the practice of modern medicine.

Integrative Mental Health at the GW Center for Integrative Medicine

Hello! 

My name is Ben Bregman and I am a psychiatrist practicing at the GW Center for Integrative Medicine.   

I hope to do several things with this blog.  

First, I will make an argument for the value of a resilience focused approach to mental health based on the scientific literature and my clinical experience.  

Second, I will write about resilience factors in human physiology, psychology and culture that people can integrate into their day-to-day activities to help them live healthier and happier lives. 

Third, I will point my readers to resources they can use to develop their own personal path to resilience. 

Finally, based on the information I present in this blog, I will articulate a way we as a culture and world can live more resiliently. 

Looking forward to the journey.