Gift From Within - PTSD Resources for Survivors and Caregivers

Speech given at the ISTSS Annual Conference, November 2000. "Reprinted by permission of Elsevier Science," Cultivating Resiliency In Youth," Carl Bell, MD, Journal of Adolescent Health, Vol 29, No5, 2001, pp 375-81 by The Society for Adolescent Medicine" A hyper-text is included to the Journal of Adolescent Health Homepage at http://www.elsevier.com/locate/jahonline and to ScienceDirectTM at http://www.sciencedirect.com. Cultivating Resiliency in Youth CARL C. BELL, M.D. This paper highlights characteristics of resiliency and the importance of strengthening resiliency and how to build it. The neuropsychiatry of traumatic stress is underscored and more esoteric resiliency-building activities are discussed. © Society for Adolescent Medicine, 2001 Characteristics of Resiliency Apfel and Simon [1], Masten and Coatsworth [2], and Wolin and Wolin [3] outline the characteristics of resiliency as: (a) having curiosity and intellectual mastery; (b) having compassion - with detachment; (c) having the ability to conceptualize; (d) obtaining the conviction of one's right to survive; (e) possessing the ability to remember and invoke images of good and sustaining figures; (f) having the ability to be in touch with affects, not denying or suppressing major affects as they arise; (g) having a goal to live for; (h) having the ability to attract and use support; (i) possessing a vision of the possibility and desirability of restoration civilized moral order; (j) having the need and ability to help others; (k) having an affective repertory; (l) being resourceful; (m) being altruistic toward others; and (o) having the capacity to turn traumatic helplessness into learned helpfulness. In addition, to these characteristics of resiliency there are more esoteric characteristics of resiliency such as: (a) having a sense of "Atman" (True Self); (b) developing "kokoro" (heart), also known as "indomitable fighting spirit" [4]; (c) having a totem - an animal spirit that lives inside; and (d) being able to cultivate "chi" (the Chinese word for internal energy) [5,6]. Building Resiliency The importance of strengthening resiliency cannot be emphasized enough. The strategy for developing emotional resilience is very similar to how one develops muscular strength. The model for developing muscular strength is that you have to exercise the muscles to make them strong, and, once you obtain strength, you have to "use it or lose it." Unfortunately, we frequently see the same lack of proactive development of emotional strength or resiliency as we see in muscular strength. One strategy for developing emotional strength is to develop and expand community partnerships, also known as "rebuilding the village" [7]. Although it is difficult to conduct experiments that permit traditional scientific criteria to be applied to community- based interventions such as community organization, such efforts are producing promising results regarding various health indicators. By "rebuilding the village" you increase the likelihood that youth will have the "ability to attract and use support." Further, communities with social infrastructure have less trauma generated incidents (e.g. violence) as the social infrastructure prevents promulgation of such behaviors [8]. Another essential feature of emotional resiliency is physical health [9]. Thus providing access to health care is an important strategy for building resiliency. For example, not having access to lead screening could lead children to have brain damage which would prevent the resiliency characteristic of having the ability to conceptualize, the capacity for curiosity and intellectual mastery. The same would be true for not having access to treatment for depression or traumatic stress. Improving bonding, attachment, and connectedness dynamics is another key component for strengthening resiliency [10,11]. Low levels of parental warmth, acceptance, and affection and low levels of cohesion and high levels of conflict and hostility have been associated with a lack of support within families [12-15]. Being bonded, attached, and connected allows for the development of the ability to remember and invoke images of good and sustaining figures. Developing closeness, increasing positive family statements, facilitating communication clarity, and encouraging emotional cohesion helps to develop supportive family relationship processes. By paying attention to the attributes of the family (i.e., beliefs, values, emotional warmth, support, organization, and communication) strategies can be developed within the family to strengthen it [16]. Resnick et al. [17] emphasizes the importance of connectedness within the family and school a variable that is associated with health and the avoidance of risky behaviors in adolescents. Improving self-esteem by facilitating a sense of connectedness (feeling satisfaction from being connected to valued people, places or things), a sense of models (models that youth can use make sense of the world), a sense of uniqueness (acknowledging and respecting the qualities and characteristics about themselves that are special and different), and a sense of power (a feeling of competence to do what they must) helps to support resiliency characteristics. Specifically, the ability to conceptualize, the development of curiosity and intellectual mastery, and the maintenance of resourcefulness [18,19]. Resiliency can be reinforced by providing youth the opportunity to increase individual social skills, e.g. communication, leadership skills, problem solving, resource management, the ability to remove barriers to success, and the ability to plan [20,21]. Further, family interventions that promote resiliency combine behavioral parent training techniques with other intervention components based in family systems theory that are designed to improve family relations an important social skill [22]. In addition, parenting practices, referring to the methods and styles of parenting or the goal-directed behaviors through which parents perform their parental duties, designed to control and socialize the child have an influence on resiliency in children. Providing parents' social skills on how to be effective in their application of discipline by avoiding harsh discipline and using positive parenting skills has been shown to reduce violence [14,23]. Further, teaching parents the social skills on how to provide supervision and monitoring of the child, extend their involvement with their children, and increase their knowledge of their child's activities and whereabouts has been shown to decrease the possibility of engaging in risky behavior. These skills support the development of the characteristics of resiliency such as the ability to attract and use support, the need and ability to help others, having altruism toward others, having compassion-with detachment, and having an affective repertory. The adult protective shield can be reestablished by providing family-oriented interventions to change parenting styles and practices that can increase a sense of social support and reduce the risk for exposure to traumatic events. Such interventions increase parental predictability and monitoring of children, and decreases negative parenting methods [12,13,24]. It is clear that a lack of parental monitoring, represented at its extreme by neglect and poor discipline methods and conflict about discipline, has been related to participation in delinquent and violent behavior for a range of populations. Familyoriented interventions allow for the development of a vision of the possibility and desirability of restoration civilized moral order, and the ability to be in touch with affects, not denying or suppressing major affects as they arise. Finally, minimizing the effects of trauma can encourage resiliency. Essentially, the strategy involved here is to support the transformation of traumatic helpless into learned helpfulness. Such a shift facilitiates the need and ability to help others, altruism toward others, and the development of compassion with detachment. If children can be identified immediately after suffering a traumatic stressor and helped to cope with that stressor, they will be less prone to engage in self-destructive behaviors such as drug abuse, school failure, unsafe sex, and violence. If a child is traumatized and are not treated for years, then even after they successfully obtain insight oriented psychotherapy and they "see the light," they will still have years of negative behavioral habits that will be relatively ingrained and hard to extinguish without a great deal of practice. Neuropsychiatry of Traumatic Stress It is clear that patients exposed to violence and trauma experience acute and chronic physiologic responses. Traumatic stress affects the catecholamine system, hypothalamic-pituitary-adrenal axis (HPA), hypothalamic-pituitary-gonadal axis (HPG), and neuropsychiatric status. The catecholamines system's response to trauma can be understood by the following observations. Children have been found to have an increased responsivity of the sympathetic nervous system that is detectable under conditions of stress. Further, as a result of increased sympathetic responsivity, children who are exposed to chronic trauma are frequently diagnosed as ADHD (attention deficit/hypertactivity disorder) [25,26]. These children have behavioral impulsivity and cognitive distortions that result from a use-dependent organization of the brain [27-29]. They are also characterized by persistent physiological hyper arousal and hyperactivity [27,30]. Traumatized children have: (a) increased muscle tone, (b) frequently a low-grade increase in temperature, (c) an increased startle response, (d) profound sleep disturbances, (e) affect regulations problems, and (f) generalized (or specific) anxiety [31-33]. Significant portions of these children have abnormalities in cardiovascular regulation [33]. Specifically, male preadolescent children exposed to violence exhibit a mild tachycardia during nonintrusive interviews and a marked tachycardia during interviews about specific exposure to trauma [30]. The HPA system is a nervous system/glandular system that controls the release of various hormones within the body and it has a definite response to trauma. Acute stress activates the HPA and increases levels of glucocorticoid - a hormone that mediates stress. Adaptation to chronic stress activates a negative feedback loop that causes: (a) decreased resting glucocorticoid levels, (b) decreased glucocorticoid secretion in response to subsequent stress, and (c) increased concentration of glucocorticoid receptors in the hippocampus [34-38]. Hart et al. [39] noted that maltreated preschoolers display blunted fluctuations in their daily salivary cortisol levels and this diminished responsivity was correlated with impaired social competence measured by teachers. Additionally, adolescents who lived closer to the epicenter of the Armenia earthquakes showed significantly lower baseline cortisol levels and greater afternoon suppression of salivary cortisol by dexamethasone [40]. Further, only adolescents who had high levels of intrusive Post Traumatic Stress Disorder (PTSD) symptoms had altered HPA system functioning. Preliminary data from prospective longitudinal study of sexually abused girls indicate they have significantly higher morning cortisol levels than their gender-, age-, race-, SES-, and family constellation- matched controls. This elevation is still present a year or more after the abuse has been reported to a child protective services agency [41,42]. These preliminary observations were born out and showed major neuroendocrine (especially in the corticosteroid and thyroid functions) disturbances in sexually abused girls [43]. The HPG system is the nervous system/sex glandular system and the axis' has a specific response to trauma. There is some evidence that the affect on the HPG system may have an affect on hormones (e.g. cortisol, testosterone, dihydroepiandrosterone, and androstenedione) that have behavioral effects in males. Because aggressive behavior and acting out has been correlated with lower gonadal steroid and higher androstenedione in boys [44], it may be that the neuroendocrine response to traumatic stress may contribute to behavioral problems in traumatized children. Clinical lore suggests that sexually abused girls undergo earlier physical maturation may be an accurate observation and occurs owing to the neuroendocrine response girls have to trauma [45]. The neuropsychiatry of traumatic stress is being clarified by modern neuropsychiatric technology. The evidence reveals that high levels of circulating glucocorticoids have a significant effect on memory. This is thought to be a function of the fact that sustained activation of the glucocorticoid system under conditions of prolonged stress eventually leads to cell death in the hippocampus [46,47]. Gurvitz et al. [48] found both left and right hippocampi were significantly smaller in PTSD subjects compared to combat control and normal subjects. Further, Vietnam veterans with the most intense combat exposure and with the most severe PTSD had an average shrinkage of over 22% in their hippocampus [48]. Similarly, Bremner et al. [49] found that Vietnam combat veterans with PTSD have an 8% reduction in the volume of their right hippocampus. Cushing disease, a hormone condition in which tumors in the adrenal or pituitary glands or use of corticosteroid drugs for a prolonged period of time causes the adrenal glands to secrete high levels of adrenocorticotrophin hormone and of cortisol. One of the major problems with Cushing disease is the patient's problems with short-term memory-an aspect of memory for which the hippocampus is especially vital. Comparison of hippocampal volume in adult survivors of childhood abuse with subsequent PTSD with matched controls reveals that PTSD patients have a 12% smaller left hippocampal volume relative to the matched controls (p _ .05), without smaller volumes of comparison regions (amygdala, caudate, and temporal lobe) [50]. Women who re- ported being severely sexually abused in childhood had significantly reduced (5% smaller) left-sided hippocampal volume compared to the nonvictimized women. Hippocampal volume was also smaller on the right side, but this failed to reach statistical significance [51]. Left-sided hippocampal volume correlated highly (rs _ _0.73) with dissociative symptom severity, but not with indices of explicit memory functioning [51]. Shalev [52] noted that PTSD forms a "biopsychosocial trap" that causes permanent alteration of neurobiological processes (i.e. hyperarousal and excessive stimulus discrimination, acquisition of conditioned fear responses to trauma-related stimuli, altered cognitive schemata, and social apprehension). Shalev [52] also proposed that if the PTSD patient's physiologic responses can be conditioned to be able to tolerate a wider range of distress, they might not fall in to this "biopsychosocial trap." Esoteric Aspects of Building Resiliency One esoteric aspect of developing resiliency is cultivating a sense of "Atman"-True/Real Self [53,54]). Everyone has a sense of "self" or "be-ing"-an "internal observer" which is unchanging and eternal. The awareness of this "be-ing" begins after the development of abstract thinking and life events can clarify or confuse the development of this potentially very strong anchor of life. Some know it as "spirit," "place," "ego," or "soul." Clarifying the "Atman" involves the meditative practice of centering, i.e., maintaining continuous awareness of an object even in the presence of distractions, which develops steadiness. Steadiness is the mental quality that helps one's awareness stay focused on an object, even in the presence of distractions. The meditative practice of concentration develops clarity. Although concentration appears similar to centering, it is different. When centering, one is concerned only with maintaining awareness of the object, not with focusing on the details of the object. During concentration, however, observing the details of the object as precisely as possible is important, and this develops mental clarity. The practice of the meditative practice of attending is also critical to the practice of clarifying the "Atman." These are techniques that involve focusing on the sensations of breathing and simultaneously paying precise attention to distractions such as thoughts, sensations, or emotions as they come and go. The meditative practice of developing attending techniques cultivates pliancy. Pliancy is the mental quality that allows one to change a focus easily. Pliancy helps the mind disengage from the thought, impulse or emotion and relieves the distress without acting on it. The meditative practice of attending techniques also trains the mind to notice thoughts, sensations, and emotions precisely. Thus, with continued practice, the mind notices phenomena that it would ordinarily have ignored. Accordingly, the meditative practice of attending also develops warmth. Warmth is the mental quality that reduces the mind's tendency to repress distressing contents [55]. Certain meditative exercises such as Tai Chi and Chi Kung involve the meditative practices of centering, attending, and concentration that develop the mental qualities of steadiness, pliancy, warmth, and clarity. Thus, these exercises lend themselves to the development of mindfulness that will allow practitioners to explore their thinking, feelings, attitudes and self-concepts - all helping to clarify the "Atman." These attributes of Tai Chi and Chi Kung also promote the development of the resiliency factors of: (a) resourcefulness; (b) curiosity and intellectual mastery; (c) compassion - with detachment; (d) ability to conceptualize; (e) ability to be in touch with effects, not denying or suppressing major effects as they arise; and (f) an effective repertory. Another esoteric aspect of developing resiliency is referred to as "building heart" or developing an "indomitable fighting spirit." "Heart" creates a goal to live for and helps develop the conviction of one's right to survive. The concept is a simple one. By encouraging individuals to "go the extra mile," a person can practice calling up emotional reserves until they trust that they have a stockpile of conviction and resiliency. Building "heart" in individuals is a preventive public health strategy designed to inoculate against the potentially negative effects of stress and trauma. "Heart" can be built in sports or other spiritual endeavors [4]. As distress and traumatic stress cause acute and chronic physiologic changes, it is important to build physiologic resiliency. Just as stress (a negative biopsychosocial experiences) changes neuroendocrine responses in the body, positive biopsychosocial experiences change neuroendocrine responses in the body. Positive biopsychosocial experiences can be cultivated by taking advantage of the physiologic advantages of Chi Kung. Such exercises strengthen psychoneuroendocrinology and are fat burning exercises that increase endurance without undue cardiovascular stress [56]. Depending of the time of day, the body has different sources of energy. At 6:00 AM the body's short-term source of energy - glycogen that is stored in the liver - is depleted from the lack of food intake during sleep. As a result, the body releases corticotrophin (ACTH) a hormone from the pituitary, which converts protein and fat into sugar that can be used for energy until the first meal. This process is called gluconeogenesis and is carried out when ACTH goes to the adrenal gland causing it to produce cortisol. Accordingly, 6:00 AM is the best time to do exercises to burn fat and redistribute proteins in the body. In addition, it is useful to have cortisol, a youthful, energizing hormone, to be actively circulating throughout the body in the morning. ACTH is produced from "big ACTH" which is composed of ACTH and the bodies own form of morphine (beta lipotrophin which contains betaendorphin and enkephalin). When ACTH is formed the beta-endorphin also is released in the body - causing an increased tolerance to pain, temperature changes, etc. Although the Chi Kung exercises are very slow and do not cause extreme respiratory or cardiovascular stress, they result in strength and endurance by virtue of them training the body to move in "one piece" and they use fat as a source of energy [5,57]. With aging the immune function undergoes adverse changes, and T cells, which have a central role in cellular immunity, show the largest age-related differences. Thymus involution is the apparent underlying cause and results in increased incidence of malignancy, infectious disease, and autoimmune disorders with age [58]. Habitual physical activity has been shown to enhance activity of macrophages, natural killer cells, lympokine activated killer cells, neutrophils and regulating cytokines increasing resistance to viral infection and preventing the formation of malignant cells [58,59]. Thus, habitual physical activity may check certain aspects of age-related decline in T cell function (e.g., reduced mitogenesis and decreases in the production of certain types of cytokine). Data suggest the incidence and mortality rates for certain types of cancer are lower among active subjects [60]. Slow exercises are probably better for retaining immunocompetence than strenuous aerobic exercises. Athletes are not clinically immunodeficient, yet endurance athletes are at increased risk for illness especially upper respiratory tract infection. In athletes, neutrophils appear to be down regulated, and this may alter resistance to illness. Down regulation of neutrophils occurs as a function of limiting chronic inflammation from exercise [61]. Thus in theory, moderate exercise (such as Chi Kung) should be better able help to reverse the adverse effects of aging on the immune system by increasing the production of endocrine hormones and causing less accumulation of autoreactive immune cells by enhancing the programmed cell death. In theory, Chi Kung is particularly suited to reversing the adverse effects of aging as the exercises are designed to be timed with the circadian rhythms of key endocrine hormones in addition to physically stimulating the areas in which the thymus gland, the adrenal glands, and gonads are located. Further, exercise has been shown to enhance neurogenesis in the hippocampus which has been associated with enhanced learning and memory (see above for the hippocampus' role in the traumatic symptom of memory loss) [62]. Finally, it is also possible to build psychological resiliency by doing Chi Kung exercises. Alexander [63] made observations about "expressive innervations." When the mind is in one emotional state or another, the expression of this emotional state can be observed in the breathing (e.g., deep sighing respiration as seen in depressed individuals, panting respiration as seen in panicked individuals, holding the breath as seen in concentrating individuals, irregular breathing as seen in upset individuals, deep inspiration as seen in surprised individuals). Just as the mental state of an individual influence the person's breathing patterns, similarly the breathing patterns can have an influence on the person's mental state. By learning to control the breathing allows the individual to control their thoughts. Conclusion The paper outlines several key principles necessary to build resiliency in youth. In addition to articulating the characteristics of resiliency, it is important to clarify the process for building resiliency in youth. Further, the language used to clarify these processes need to be metaphoric and simple, as it takes a comprehensive community effort to facilitate youth resilience, and such efforts need easy to understand paradigms to guide their work. Finally, if some of the members of the Society of Adolescent Medicine want to support efforts to build resiliency in youth, I recommend the following parable. When I was in medical school I was told that, if a child came into my office with a rat bite, and I sat in my office, examined the child, and then gave the child a tetanus shot, some antibiotics, and carefully dressed the wound, I would be a good doctor. If however, 100 children from the surrounding community came into my office, each with rat bites, and I sat in my office, examined the child, and then gave the child a tetanus shot, some antibiotics, and carefully dressed the wound and that was all - then I should have my medical license revoked. The reason being that I did not go out into those children's community and get rid of the rat. In this case the rat is a lack of vision and leadership to insist that society provide lessons in resiliency in our children. References 1. Apfel RJ, Simon B (eds). Minefields in Their Hearts. New Haven: Yale University Press, 1996:9-11. 2. Masten AS, Coatsworth JD. The development of competence in favorable and unfavorable environments. Am Psychol 1998;52:205-20. 3. Wolin S, Wolin SJ. The challenge model: Working with strengths in children of substance-abusing parents. Child Adol Psych Cl 1996;5:243-56. 4. Bell CC, Suggs H. Using sports to strengthen resiliency in children-Training "Heart." 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Effects of maximal exercise on natural killer (NK) cells cytotoxicity and responsiveness to interferon-alpha in the young and old. J Gerontol 1998;53:430-7. 60. Nieman DC. Exercise immunology: Practical applications. Int J Sports Med 1997;18 (suppl 1):S91-S100. 61. Mackinnon LT. Future directions in exercise and immunology: Regulation and integration. Int J Sports Med 1998;19(suppl): S205-9. 62. van Praag H, Crhistie BR, Sejnowski TJ, et al. Running enhances neurogenesis, learning, and long-term potentiation in mice. Proc Natl Acad Sci 1999;96:13427-31. 63. Alexander F. Psychosomatic Medicine. New York: W. W. Norton & Co., 1950. From the Department of Public and Community Psychiatry and Department of Psychiatry and Public Health, University of Illinois at Chicago, Chicago, Illinois. Address correspondence to: Dr. Carl C. Bell, Community Mental Health Council, 8704 S. Constance, Chicago, IL, 60617. Manuscript accepted June 18, 2001 Presented at the annual meeting of the Society for Adolescent Medicine, March 24, 2001, San Diego, California. Carl C. Bell, M.D., has been a practicing community psychiatrist for more than thirty-five years. He is the author of Sanity of Survival (Third World Press, Inc.) and has published over 350+ articles on mental health issues. He is President and CEO of the Community Mental Health Council, Inc., in Chicago. Dr. Carl Bell is a member of Gift From Within's Professional Advisory Board Read Dr. Carl Bell's other articles: Cultivating Resiliency Traumatic Stress and Children Exposure To A Traumatic Event Does Not Automatically Put A Person On A Path To Develop PTSD: The Importance of Protective Factors To Promote Resiliency.

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