Evidence-Based Reviews

6 keys to resilience for PTSD and everyday stress

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Ms. M, age 24, works as a magazine editor in New York City. On a December evening, she walks out of the subway and heads to her boyfriend’s apartment, looking forward to unloading her heavy bag and checking her e-mail. Out of nowhere, a man runs up behind her and smashes a huge rock into her head.

She feels momentarily disconnected from her body and surroundings but manages to scream. As the assailant runs away, 2 girls rush to her aid.

Ms. M hurts everywhere. Her glasses have been knocked off, and her orbit is fractured; her eye will require multiple surgeries. She reaches for her cell phone, but it’s slippery with blood. A bystander dials 911, and paramedics arrive within minutes.

Most persons experience trauma during their lives,1 but not usually an attack as severe as Ms. M’s. Post-traumatic stress disorder (PTSD) and other psychopathologies are not inevitable or even common, however, developing in 8% to 12% of trauma survivors.2 Why are some individuals more resilient to trauma than others?

Resilience to stress is associated consistently with at least 6 psychosocial factors: active coping styles, regular physical exercise, a positive outlook, a moral compass, social support, and cognitive flexibility (Table 1). This article describes how motivated persons can enhance these “resilience factors” to become more resistant to everyday stressors and unexpected traumas.

Table 1

6 psychosocial factors that protect against
and aid recovery from posttraumatic stress

Active coping styleProblem-solving and managing emotions that accompany stress; learning to face fears
Physical exerciseEngaging in physical activity to improve mood and health
Positive outlookUsing cognitive-behavioral strategies to enhance optimism and decrease pessimism; embracing humor
Moral compassDeveloping and living by meaningful principles; putting them into action through altruism
Social supportDeveloping and nurturing friendships; seeking resilient role models and learning from them
Cognitive flexibilityFinding good in adverse situations; remaining flexible in one’s approach to solving problems

1. Active coping style

Resilience is the process of adapting well to stress or trauma (Box 1).3-5 Learning to manage stressful situations requires active coping, which can be conceptualized as 2 types:

  • “problem-focused” (working to solve the problem)
  • “emotion-focused” (accepting and dealing with emotions caused by the stressor).
Many studies have correlated active coping with emotional well-being. A 2003 study of first-year medical students found that using problem-focused or emotion-focused coping techniques helped preserve physical and mental health during 1 year of medical school.6 In contrast, depressed persons tend to use passive coping styles, including denial and avoiding problems, substance abuse, and resignation.7
Undertaking and mastering difficult tasks appears to be effective in increasing resilience to stress. The “stress inoculation” hypothesis (Box 2)8-11 provides a plausible explanation for the observation that children who learn to cope with stress tend to become hardy adults. Successfully overcoming challenges improves self-confidence and also may alter the neurobiology of the stress response.

Prolonged-exposure therapy. PTSD development and maintenance depend in part on fear conditioning. By avoiding exposure to reminders of their trauma, survivors unwittingly solidify associations between traumatic triggers (people, places, or things that are reminders) and fear. Actively facing fears is necessary to break these associations.

Prolonged-exposure therapy was designed to help patients face their fears.12 As part of therapy, participants retell their trauma stories and engage in avoided activities in a safe environment. This treatment has been found to be highly effective in reducing PTSD symptoms, and its benefits often last longer than those conferred by pharmacologic interventions.13

CASE CONTINUED: Feeling ‘out of sync’

Ms. M remains frightened and angry after 2 months and is referred for psychological evaluation. She is diagnosed with PTSD based on her debilitating symptoms, including flashbacks, frightening nightmares, avoiding the subway, and feeling emotionally numb (which she describes as “being out of sync” with loved ones). Ms. M also complains of difficulty sleeping and irritability.

The therapist initiates prolonged-exposure treatment, including imaginal and in vivo exposure. In imaginal exposure, Ms. M tells and retells her trauma story in the safety of the therapist’s office. To desensitize herself to the memory, she listens to her recorded voice recounting her trauma. In vivo exposure involves homework, such as visiting the attack site during the day with a companion and talking with loved ones about the event. These assignments allow Ms. M to reclaim the life she lost because of severe anxiety and fear associated with anything related to the attack.


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