CanJPsychiatry 2012;57(11):651–658
In Review
Mental Illness and Mental Health: Is the Glass Half Empty or
Half Full?
Joseph M Pierre, MD1
1
Associate Director of Residency Education, UCLA Semel Institute for Neuroscience and West Los Angeles VA Medical Center, Los Angeles, California;
Co-Chief, Schizophrenia Treatment Unit, West Los Angeles VA Medical Center, Los Angeles, California; Health Sciences Clinical Professor, Department of
Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California.
Correspondence: 11301 Wilshire Boulevard, Building 210, Room 15, Los Angeles, CA 90073; joseph.pierre2@va.gov.
Key Words: diagnostic
expansion, prevalence inflation,
bereavement, adjustment
disorder, contextual utility,
neuroenhancement, mental
illness, mental health
Received and accepted March
2012.
During the past century, the scope of mental health intervention in North America has
gradually expanded from an initial focus on hospitalized patients with psychoses to
outpatients with neurotic disorders, including the so-called worried well. The Diagnostic
and Statistical Manual of Mental Disorders (DSM), Fifth Edition, is further embracing the
concept of a mental illness spectrum, such that increasing attention to the softer end of
the continuum can be expected in the future. This anticipated shift rekindles important
questions about how mental illness is defined, how to distinguish between mental disorders
and normal reactions, whether psychiatry is guilty of prevalence inflation, and when somatic
therapies should be used to treat problems of living. Such debates are aptly illustrated
by the example of complicated bereavement, which is best characterized as a form of
adjustment disorder. Achieving an overarching definition of mental illness is challenging,
owing to the many different contexts in which DSM diagnoses are used. Careful analyses of
such contextual utility must inform future decisions about what ends up in DSM, as well as
how mental illness is defined by public health policy and society at large. A viable vision for
the future of psychiatry should include a spectrum model of mental health (as opposed to
exclusively mental illness) that incorporates graded, evidence-based interventions delivered
by a range of providers at each point along its continuum.
WWW
Au cours du siècle dernier, la portée des interventions en santé mentale en Amérique du
Nord s’est graduellement accrue, allant de l’accent initial mis sur les patients hospitalisés
souffrant de psychoses aux patients ambulatoires souffrant de troubles névrotiques, y
compris ceux qu’on appelle les bien portants inquiets. Le Manuel diagnostique et statistique
des troubles mentaux (DSM), 5e édition, adopte le concept d’un spectre de la maladie
mentale, de sorte qu’on puisse s’attendre à l’avenir à ce que plus d’attention soit portée
à l’extrémité plus bénigne du continuum. Ce changement prévu remet à l’ordre du jour
d’importantes questions : comment est définie la maladie mentale, comment distinguer
entre les troubles mentaux et les réactions normales, déterminer si la psychiatrie est
coupable d’inflation de la prévalence, et à quel moment utiliser les thérapies somatiques
pour traiter des problèmes de vie. Ces débats sont bien illustrés par l’exemple du deuil
compliqué, qui est le mieux caractérisé comme étant une forme de trouble d’adaptation.
Parvenir à une définition générale de la maladie mentale est difficile, en raison des
nombreux différents contextes dans lesquels les diagnostics du DSM sont utilisés. Des
analyses rigoureuses de cette utilité contextuelle doivent éclairer les futures décisions
à propos de ce qui se retrouve dans le DSM, et de la façon dont la maladie mentale est
définie par les politiques de santé publique et la société dans son ensemble. Une vision
viable de l’avenir de la psychiatrie devrait inclure un modèle de spectre de la santé mentale
(par opposition à exclusivement de la maladie mentale) qui incorpore des interventions
classées, fondées sur des données probantes et dispensées par une série de prestataires
à chaque point du continuum.
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The Canadian Journal of Psychiatry, Vol 57, No 11, November 2012 W 651
In Review
Gone forever is the notion that the mentally ill
person is an exception. It is now accepted that most
people have some degree of mental illness at some
time, and many of them have a degree of mental
illness most of the time.
—Karl Menninger1, p 33
T
he roots of modern psychiatric nosology can be traced
back to Kraepelin’s efforts to form a classification system
for mental disorders based on careful clinical descriptions
of symptoms, course, and outcome along with a need for
public hospital census data in the United States at the turn
of the century.2,3 As psychiatry at the time centred almost
exclusively on asylum care of people with severe mental
illness, these endeavours began with sharp demarcations
between mental disorders and mental health,4,5 where most
psychiatric diagnoses consisted of subtypes of psychosis.3
Despite this start, American psychiatry transitioned away
from psychotic asylum patients toward less severely
ill outpatients, modelled along a “neurosis-psychosis
continuum” in which “everyone, patients or not, sick
or healthy, fell on that continuum somewhere.”6, p 1 This
transformation occurred during the past century in response
to 3 synergistic forces. First, the rise of psychoanalysis
drove psychiatrists into private practice–based outpatient
therapy, where the typical analysand was a collegeeducated, upper-middle class professional who paid for
service out of pocket.7 Freud himself conceded that “the
optimum conditions for (psychoanalysis) exist where it is
not needed—i.e., among the healthy.”8, p 53 Second, Adolph
Meyer, the father of American psychiatry, advocated for a
patient-centred, psychosocial approach that viewed mental
illness on a continuum, distinct from Kraepelin’s disease
model.9 Meyer advanced the Mental Hygiene Movement’s
far-reaching goals of social reform, including the belief that
mental illness was rooted in personality and stemmed from
psychological reactions and maladjustments to childhood
conflicts and other life stressors. Premorbid interventions
were directed “beyond the walls of hospitals”10, p 632 into
the community and within schools,11 thereby widening the
scope of mental health interventions in the United States and
paving the way for deinstitutionalization, the development
of community-based psychiatry, and the eventual formation
of modern federal mental health policy.4 Finally, recognition
of battle fatigue, combat exhaustion, and shell shock among
Abbreviations
AD
antidepressant
BE
bereavement exclusion
DSM
Diagnostic and Statistical Manual of Mental Disorders
MDE
major depressive episode
PTSD
posttraumatic stress disorder
SMI
serious mental illness
SSDI
Social Security Disability Insurance
652 W La Revue canadienne de psychiatrie, vol 57, no 11, novembre 2012
Highlights
•
During the past century, psychiatry has broadened
its scope, recognizing and targeting an expanding
spectrum of mental illness.
•
Diagnostic expansion has yielded inevitable debates
about overdiagnosis and prevalence inflation, with
important clinical, ethical, and economic perspectives.
•
In the future, psychiatry should embrace an overarching
model that offers graded, cost-effective, and evidencebased interventions along the mental health spectrum.
Limitations
•
Critiques about overdiagnosis must be balanced
against the serious potential for undertreatment and
should recognize the value of preventative and healthpromoting interventions for subthreshold conditions or
when no mental illness is present.
•
Evidence-based research is needed to guide optimal
interventions across a full continuum of mental health.
soldiers from World War I and II crystallized the notion that
mental illness was often caused by reactions to trauma,
particularly among people with some latent “predisposition
to maladjustment.”11, p 127 Psychiatrists participated in mass
screenings of prospective draftees during World War II, with
1.75 million men ultimately rejected from service based on
increasing recognition of neurotic, as opposed to psychotic,
symptoms and disorders.8 These psychoneurotic syndromes
were not cataloged within existing psychiatric classification
manuals, necessitating revised nosologies culminating in
the development and publication of the first DSM in 1952.12
Therefore, the first DSM was very much a reflection
of evolving American psychiatry and the prevailing
ideological, cultural, and social forces of its time.3 In
subsequent revisions, the influence of psychoanalytic
theory would lose steam, with the term reaction, which
had served to distinguish disorders caused by difficulties
in adaptation, as opposed to primary brain dysfunction,
eliminated in DSM-II, and the Kraepelinian notion that
mental illness and mental health could be demarcated
and that mental disorders consisted of multiple distinct
disease entities reemerging in DSM-III.5,13 Although its
new atheoretical model recognized no specific etiologies
for mental illnesses, DSM-III turned sharply away from
popular analytic and psychosocial theories and deliberately
aligned itself with a criterion-based medical model, with
the underlying principle that psychiatric disorders could be
validated like other medical disorders by the establishment
of a clinical description, distinction from other disorders,
and laboratory, family–genetic, and longitudinal studies.14–16
As a further departure from psychoanalytic thinking,
the DSM-III task force originally intended to discard the
distinction between psychosis and neurosis in favour of
an all-encompassing, but much more narrow, definition of
mental disorder.17 The use of the term neurotic disorders
was indeed abandoned by DSM-III-R, but plans to set a
high threshold for psychiatric diagnosis were scrapped in
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Mental Illness and Mental Health: Is the Glass Half Empty or Half Full?
favour of a “principle of inclusiveness”18, p 459 that sought
to incorporate diagnoses already widely used by clinicians,
including those lacking validity.18 The result today is that
while the diagnostic reliability of individual disorders in
the DSM has improved significantly since pre–DSM-III
editions, a reliable overarching definition of mental disorder
remains elusive,19–22 and validity remains unestablished
for most DSM syndromes.23 In addition, though the overt
presence of psychoanalysis has largely faded from the DSM,
the neurotic disorders that rose alongside psychodynamic
psychotherapy remain a strong presence, albeit with new
categorical titles seeking biologic validation (for example,
anxiety, somatoform, sexual, adjustment, impulse-control,
eating, and personality disorders). Rather than narrowing
the concept of mental illness, the number of DSM disorders
has more than tripled, from 106 disorders in DSM-I to
357 in DSM-IV.24 While this increase partly reflects finer
distinctions within categories (that is, splitting as opposed
to lumping), there is concern that this diagnostic expansion
also reflects a kind of artificial prevalence inflation—that
the threshold for defining mental disorder caseness has
been progressively lowered, with increasing encroachment
on what might have been previously considered within
normal limits. Indeed, recent epidemiologic data indicate
that about one-half of Americans will meet criteria for a
DSM-IV disorder sometime in their life,25 with a 12-month
prevalence of 26%.26 Some have even asserted that
such figures are underestimates owing to problems with
retrospective detection,27 suggesting that having a mental
illness at some point in one’s life may be, depending on
one’s definition,28 normal. Currently, as a new DSM-5
moves to further widen the spectrum of mental disorders,
the Kraepelinian tenet that psychiatry treats “people who
are sick and who require treatment for mental illnesses”5, p 348
is a matter of considerable controversy.23
Normal Reactions or Psychiatric Disorders?
Virtually all of our measures of “psychopathology”
are built on the assumption that to be
psychologically healthy is to be free of disordered
emotional and cognitive responses. According to
this standard, a coma victim might be considered the
ideal of psychological health.
—Steven C Hayes et al29, p 75
Concerns about prevalence inflation and overdiagnosis
in psychiatry often focus on a central assertion that the
DSM has increasingly medicalized or pathologized
various normal human experiences. This is a core feature
of claims that the current pandemic of major depression
and the increasingly widespread use of ADs represent
an inappropriate medicalization of normal sadness.30
Wakefield31,32 has advanced the idea that normal responses
to stressful circumstances and problems of living can be
reliably distinguished from mental illnesses by equating
mental disorder with “harmful dysfunction,”31, p 635; 32, p 149
defined as some negatively valued outcome caused by a
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failure of some internal mechanism to perform one of the
functions for which it is biologically designed through
natural selection. Therefore, proponents of the harmful
dysfunction argument hold that normal, expected, or
proportionate responses to stressors are not mental
disorders unless they involve such intensity as to imply
the failure of the intended function of a psychological
process. While the harmful dysfunction model has obvious
practical limitations, including the considerable difficulty
of establishing causality, judging the proportionality of a
response (especially when considering cultural variations),
or determining the intended evolutionary function of a
psychological process,33–35 it nonetheless highlights valid
challenges in disentangling mental disorders from normal
reactions to stressful life events.
That challenge is aptly illustrated by debates about the
removal of the BE in DSM-5. DSM-IV currently allows
that an MDE not be diagnosed if better accounted for by
bereavement (and especially if symptoms are less severe
or have been present for less than 2 months). The harmful
dysfunction analysis supports this diagnostic guideline and
has been extended to argue that proportionate depressive
reactions to other stressors (for example, ending an intimate
relationship, loss of job, and medical illness) should also
be excluded.36 Conversely, several authors have advocated
for the removal of the BE, noting that the course of
bereavement that otherwise meets MDE criteria does not
differ significantly from an MDE associated with any other
stressor or with no evident stressor at all.37
Charges of psychiatric overdiagnosis often begin with a
core assertion, inherent to the harmful dysfunction model,
that so-called normal and pathological are mutually
exclusive states, such that normal processes should not be
labelled pathological disorders. This viewpoint values the
pre–DSM-II concept of a reaction, but posits that normal
reactions are distinct from mental illness and, therefore,
outside the domain of psychiatry. Thus the distinction
between normal and pathological is not merely semantic,
but clinically pertinent because of implications about
appropriate treatment. At the most basic level, it has
been argued that nondisorders should not be treated by
psychiatrists at all. For example, in opposing the removal
of the BE, Frances38 noted that “it would be unfortunate
for psychiatry to prematurely roam into problems usually
better handled by family and other cultural institutions.”p 2
However, it is unclear why such problems would be better
handled by nonprofessionals, especially given that many
people do not have access to family or community supports.
Critics of conflating normal reactions with mental illness
are often particularly wary of pharmacotherapy. With
bereavement, there is a fear that the overdiagnosis of
depression would result in widespread prescription of
ADs, with unnecessary exposure to potentially harmful
side effects.38 Such concerns must be considered within
an overall risk–benefit analysis that considers whether the
existing BE actually results in false negatives in clinical
The Canadian Journal of Psychiatry, Vol 57, No 11, November 2012 W 653
In Review
practice and balances the associated risk of undertreatment
against the potential for overtreatment of false positives
should the BE be removed. Though critics of overdiagnosis
often suggest that pharmacotherapy may not be helpful for
bereavement—or worse, that it could interfere with what
is a normal reparative process—at least 2 uncontrolled
studies found that AD treatment can improve measures of
both depression and grief among bereaved people otherwise
meeting MDE criteria.39,40
Advocates of eliminating the BE make a key distinction
between normal and complicated grief, and hold that
normal grief can be reliably distinguished from an MDE
through careful clinical assessment. Normal and adaptive
grief is a difficult, but culturally sanctioned, healthy process
that is “the price we pay for love and attachment.”41, p 1097 It
features sadness and other possible symptoms of depression,
but also positive experiences that are part of the healing
process. Therefore, it rightly belongs in the category of a
DSM V code—a condition that is not a disorder, but may be
a focus of a clinical attention. In contrast, complicated grief,
reflecting a pathological disruption of the normal grieving
process, but with symptomatic manifestations, clinical
course, and therapeutic response distinct from an MDE, has
been proposed as a new category for DSM-5.41–43 Including
complicated grief in DSM-5 as distinct from normal
bereavement could mitigate concerns that eliminating the
MDE BE would result in psychiatry co-opting the normal
grieving process. However, doing so would highlight that
no other stressor-driven response (for example, to serious
or terminal medical illness) is granted special status, despite
similarly specific phenomenologies, and raises the question
of why complicated grief should not simply be included in
the larger category of adjustment disorders.
Adjustment disorders have a unique place within the
atheoretical DSM (along with conversion disorder, PTSD,
and acute stress disorder) that retains an association with
stressor-related causality. There are no symptomatic criteria
for adjustment disorders, such that diagnosis is based on
vaguely defined “emotional or behavioral symptoms” that
arise in response to “an identifiable stressor” and are clinically
significant, as defined by either “marked distress in excess
of what would be expected” and “significant impairment
in social or occupational functioning.”44, p 626 As with
MDE, bereavement is listed as an exclusion for adjustment
disorders in DSM-IV, unless “the reaction is in excess of,
or more prolonged than, what would be expected.”44, p 626
These ill-defined criteria result in the same challenges
with distinguishing normal reactions from pathological
responses discussed above, including how to judge the
proportionality of a reaction, and tautologic problems
regarding clinical significance.45 As a result, many have come
to regard adjustment disorders as a “wastebasket” or “wild
card”46, p 409 diagnosis, occupying a “lynchpin”47, p 123 position
between normality and problems of living (V codes), and
pathologic psychiatric states.47 Various proposals have been
made to improve the sensitivity of adjustment disorders in
DSM-5, including conceptualizing adjustment disorders
654 W La Revue canadienne de psychiatrie, vol 57, no 11, novembre 2012
on a “stress response”48, p 137 spectrum that includes
PTSD,48 and raising the clinical significance criterion
to include both distress and functional impairment.49,50
Indeed, a significant overhaul of adjustment disorders as
a more reliable, narrowly defined, and clinically useful
diagnostic category is in order. Ideally, a future scientific
model of how stress and resilience interact to maintain a
homeostatic balance between mental health and mental
illness will be integrated into the diagnostic understanding
of all psychiatric disorders.51–53 When that occurs, a discrete
category for adjustment disorders may become obsolete. In
the meantime, regarding bereavement, grief should remain
as a V code, complicated grief should be recognized as a
variant of adjustment disorders (as it already is within the
International Classification of Diseases) that includes the
possibility of chronicity (as, by definition, the stressor does
not resolve), and bereaved patients meeting MDE criteria
for a sustained period should be diagnosed as such.54 The
latest proposals for DSM-5 indicate movement in this very
direction.55
Mental Illness in Context
We envision a future when everyone with a mental
illness will recover, a future when mental illnesses
can be prevented or cured, a future when mental
illnesses are detected early, and a future when
everyone with a mental illness at any stage of life
has access to effective treatment and supports—
essentials for living, working, learning, and
participating fully in the community.
—The President’s New Freedom
Commission on Mental Health56, p 1
[It’s] the economy, stupid!
—James Carville57, p 1
Although it is practical and perhaps reassuring to think
of mental disorders as discrete entities or “natural
kinds,”58, p 1037; 59 existing evidence supports a continuum
between mental illness and mental health with indistinct
borders.23,60–62 Even the DSM-IV concedes that
there is no assumption that each category of mental
disorder is a completely discrete entity with absolute
boundaries dividing it from other mental disorders
or from no mental disorder.44, p xxii
However, this lack of discrete boundaries does not mean
that there is no such thing as mental illness, or that the
boundaries are completely arbitrary. In the absence of
established validity for DSM disorders, defining what
constitutes a mental disorder is typically based on
judgments of clinical significance and clinical utility.5,63
However, facilitating clinical work is but one purpose of
psychiatric diagnosis, highlighting the larger and more
heterogeneous concept of “contextual utility”23, p 375 in which
fluid diagnostic thresholds are necessarily influenced by the
specific questions asked of diagnosis.
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Mental Illness and Mental Health: Is the Glass Half Empty or Half Full?
In general, clinical work favours a low threshold for defining
mental illness to facilitate the provision of help to helpseeking people and to minimize harm to patients as a result of
failing to identify serious conditions (that is, false negatives).
Many clinicians do not rely on DSM for diagnosis,64 are
sensitive to the suffering associated with mild disorders,65,66
and are unlikely to turn away help-seeking people because
they do not have a threshold disorder. Also, it is often
the existence of a putative intervention that determines
whether treatment is offered, regardless of whether that
intervention targets a disorder, per se. The expansion of
psychiatric nosology to accommodate neurotic disorders
during the 20th century was fuelled by the availability and
apparent efficacy of psychodynamic psychotherapy for
anxiety arising from life problems and disorders alike, just
as the subsequent ascendance of psychopharmacology has
now paved a path toward neuroenhancement, where drug
treatments are requested by people without disorders and
prescribed in kind by clinicians hoping to improve wellbeing.67–69 Ethical considerations about potential risks,
need for regulation, and the place of neuroenhancement in
psychiatry are vital topics for discussion,70–73 but, rather than
leading the way, have been following what appears to be an
inevitability. Some authors have voiced similar concerns
about “disease mongering”74, p 886 on the part of drug
companies with vested interests in the further growth of the
psychotropic market through diagnostic expansion.74,75 In
fairness, those concerns could be extended to the psychiatry
industry as a whole, which aims to relieve suffering but
also stands to benefit from an increasingly wider domain
of pathology.76 Ultimately, while concerns about conflicts
of interest are important, the growth of the consumerdriven neuroenhancement market will be determined
by the perceived effectiveness of the product line and
the desirability of those effects. This vision of the future
highlights the subjectivity of distress, and demonstrates
how help seeking—despite serving as a proxy for distress
and, therefore, clinical significance in the DSM—should
not be equated with mental illness. As a result, although
the principle of inclusiveness that shaped DSM-III suggests
otherwise, mental disorders are not simply “what clinicians
treat.”77, p 10 Simultaneously, help-seeking behaviours
are complex and variable, with individual and cultural
determinants,78–80 such that concerns about overdiagnosis
and overtreatment must be balanced against the realities of
poor insight and treatment adherence on the part of patients,
stigmatization, public skepticism toward psychiatry, and
the serious potential for undertreatment.81–83
On the other side of the clinical equation, limited financial
resources available for public health care, private insurance,
and government disability entitlements favour higher
thresholds of mental disorder.84,85 This economic reality has
led to efforts to stratify disorders according to severity with
definitions of SMI or to incorporate functional disability
(as opposed to only distress or help seeking) into public
health definitions of mental disorder.66,84–87 Ironically, these
efforts at rationing have the potential to cause artificial
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prevalence inflation. For example, unlike the rest of
medicine, where clinical intervention for garden-variety
complaints (for example, pain, cough, dyspepsia, and
itchiness) in the absence of a disorder or disease is both
routine and reimbursable within insurance plans, mental
health reimbursement tends to require a threshold DSM
disorder. Indeed, the DSM-III’s principle of inclusiveness,
along with its emphasis on categorical disorders as opposed
to symptoms, was implemented owing to concerns that
a narrow definition of mental illness would discourage
insurance reimbursement for what clinicians regularly
encountered in practice.17 However, DSM’s inclusiveness
does not render clinicians immune to health care rationing,
such that overdiagnosis (that is, diagnosing an SMI in
place of less severe disorder) has become incentivized to
justify care. Although the category of adjustment disorders
was created, in part, to allow for the diagnostic coding of
subthreshold disorders,47 the diagnosis of an adjustment
disorder occurs most commonly in primary care and
consultation–liaison psychiatry rather than in psychiatric
practice.88 This can be explained both by the stressful impact
of medical disorders and by patients tending not to seek
psychiatric care for adjustment disorders,83,89 as well as by
the likelihood that an adjustment disorder is misdiagnosed
as a depressive disorder, both in epidemiologic studies90
and by psychiatrists in clinical practice for the purposes
of reimbursement. This potential for overdiagnosis also
pervades the SSDI program in the United States, where
having an SMI is highly incentivized to increase the chances
of qualifying for benefits. Patients, and supporting clinicians,
are well aware that having an SMI is more likely to result in
a successful SSDI application, especially because having a
substance abuse disorder alone is no longer adequate.91 This
has created an environment that promotes the “iatrogenic
malingering”92, p 253 of psychiatric symptoms, and psychotic
symptoms in particular,92 such that mental disorders have
become the single largest source of disability,93 with
about one-third of mental health beneficiaries carrying
a diagnosis of schizophrenia.94 Recent data reveal that
the proportion of SSDI awards for psychiatric disorders
has increased from 11% in 1981 to 41% in 2006.93 These
startling figures suggest that while third parties often seek
to raise the bar that defines the threshold for SMI, powerful
financial incentives can drive both clinicians and patients
to jump higher by overrating the severity and chronicity
of functional impairments associated with mental illness.
Unfortunately, this practice may disincentivize recovery,
and could, ironically, result in denial of future health care
coverage based on preexisting conditions.
Conclusion
Human life begins on the far side of despair.
—Jean-Paul Sartre95, p 119
The ever-widening borders of mental illness can be
attributed to the rise of neurosis in the past century,
the creation of new disorders representing diagnostic
The Canadian Journal of Psychiatry, Vol 57, No 11, November 2012 W 655
In Review
subcategories (for example, complicated grief), increasing
attention to, and the availability of, putative interventions
at the milder end of the diagnostic spectrum, and incentives
to have a threshold psychiatric disorder to qualify for
health care benefits. In addition, society’s tolerance of
suffering and impairment varies along with its expectations
of psychiatry.96 Freud (see Freud and Breuer97) famously
conceded that suffering was inevitable, but believed that
psychoanalysis could at least transform “hysterical misery
into common unhappiness.”p 306 Developed Western societies
now increasingly regard happiness as an entitlement,98 with
pharmaceutical companies and the industry of psychiatry
as a whole advertising the path of attainment. More than
ever, people are open to taking medications for day-today stresses and interpersonal problems,99 such that a
substantial proportion of those treated with ADs have no
mental disorder,100 despite recent data casting doubt on the
efficacy of ADs for mild depression.101–103 Therefore, an
overly broad concept of mental disorder runs the risk of
overpathologizing and overmedicating reactions to stress,
overestimating the ability to eliminate unhappiness, and
neglecting the potential value of suffering.
Although many may consider the simplest definition of a
mental disorder to be what is in the DSM, psychiatry is
increasingly embracing a reality that there is a continuum
between mental illness and mental health. Ultimately,
distinguishing between the 2 may be akin to asking whether
a glass is half empty or half full (for example, is a person
with an IQ of 85 best characterized as having mildly
impaired or nearly average intellectual functioning?). Rather
than focusing on psychiatric disorders as DSM currently
does, an overarching future vision for psychiatry could
conceptualize a “particle and wave”62, p 168 spectrum model
of mental health that includes normal suffering and reactions
to stressors, troublesome complaints and symptoms,
subthreshold disorders and forme frustes, as well as more
clearly demarcated SMI. A truly continuous view of mental
health would rely less on categorical disorders and instead
recognize “cross-cutting symptom”104, p 648 dimensions, not
only across disorders but also along the normal–pathological
continuum.104 This focus on mental health rather than mental
illness would deliberately avoid diagnosing psychiatric
disorder at all points along the help-seeking spectrum,
potentially reducing stigma and the risk of overtreatment.
From an intervention standpoint, care would be taken to not
assume that effective treatments at one end of the spectrum
should be applied in blanket fashion at other points, and
would instead follow evidence-based, comparative, risk–
benefit data from clinical research investigating various
interventions, including no treatment and (or) watchful
waiting; self-help, coping, and (or) resiliency-promoting
strategies; exercise and other lifestyle interventions;
psychotherapies; and pharmacotherapy. Finally, a viable
public health policy that balances the cost-effectiveness
of focusing resources on more narrowly defined SMI with
investing in preventative care and management of milder
conditions that themselves carry considerable long-term
656 W La Revue canadienne de psychiatrie, vol 57, no 11, novembre 2012
morbidity may require a stepwise treatment model that
integrates care provided by not only psychiatrists but also
primary care clinicians, paraprofessionals, lay people,
peers, and patients themselves.66,96
Acknowledgements
The Canadian Psychiatric Association proudly supports the
In Review series by providing an honorarium to the authors.
The author reports no conflicts of interest in relation to this
manuscript.
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Clinical Psychology Review 30 (2010) 479–495
Contents lists available at ScienceDirect
Clinical Psychology Review
Resilience and mental health
Dmitry M. Davydov a,c,⁎, Robert Stewart b,1, Karen Ritchie c,d,2, Isabelle Chaudieu c,2
a
Moscow Research Centre of Narcology, 37-1 Lublinskaya ulitsa, Moscow, 109390, Russia
King's College London (Institute of Psychiatry), Section of Epidemiology (Box 60), De Crespigny Park, London SE5 8AF, UK
c
INSERM, U.888, Hôpital la Colombière, 34093 Montpellier Cedex 5, France
d
Imperial College, Department of Neurosciences and Mental Health, London, UK
b
a r t i c l e
i n f o
Article history:
Received 8 September 2009
Received in revised form 9 March 2010
Accepted 17 March 2010
Keywords:
Psychological resilience
Mental health
Mental disorders
Immunity model
a b s t r a c t
The relationship between disease and good health has received relatively little attention in mental health.
Resilience can be viewed as a defence mechanism, which enables people to thrive in the face of adversity and
improving resilience may be an important target for treatment and prophylaxis. Though resilience is a
widely-used concept, studies vary substantially in their definition, and measurement. Above all, there is no
common underlying theoretical construct to this very heterogeneous research which makes the evaluation
and comparison of findings extremely difficult. Furthermore, the varying multi-disciplinary approaches
preclude meta-analysis, so that clarification of research in this area must proceed firstly by conceptual
unification. We attempt to collate and classify the available research around a multi-level biopsychosocial
model, theoretically and semiotically comparable to that used in describing the complex chain of events
related to host resistance in infectious disease. Using this underlying construct we attempt to reorganize
current knowledge around a unitary concept in order to clarify and indicate potential intervention points for
increasing resilience and positive mental health.
© 2010 Elsevier Ltd. All rights reserved.
Contents
1.
2.
3.
4.
5.
6.
7.
8.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Current conceptualizations of resilience . . . . . . . . . . . . . . . . . . . .
A biopsychosocial (multi-level) construct for mental resilience . . . . . . . . .
3.1.
Individual level of resilience . . . . . . . . . . . . . . . . . . . . . .
3.2.
Group level of resilience . . . . . . . . . . . . . . . . . . . . . . . .
Resilience approaches in mental health research . . . . . . . . . . . . . . . .
4.1.
The harm-reduction approach (Fig. 2). . . . . . . . . . . . . . . . . .
4.2.
The protection approach (Fig. 2) . . . . . . . . . . . . . . . . . . . .
4.3.
The promotion approach (Fig. 2) . . . . . . . . . . . . . . . . . . . .
Some potential multi-level mechanisms conferring resilience . . . . . . . . . .
5.1.
Genetic, epigenetic and gene–environment mechanisms . . . . . . . . .
5.2.
Behavioural and associated neuronal mechanisms . . . . . . . . . . . .
Measures of mental resilience. . . . . . . . . . . . . . . . . . . . . . . . .
Some challenges for future resilience research . . . . . . . . . . . . . . . . .
7.1.
Challenge 1: Moderation of individual- and group-level factors. . . . . .
7.2.
Challenge 2: Mediating relationships between different resilience factors .
7.3.
Challenge 3: Specificity of resilience mechanisms . . . . . . . . . . . .
7.4.
Challenge 4: Time lag in resilience . . . . . . . . . . . . . . . . . . .
7.5.
Challenge 5: Cost and organizational complications of resilience research .
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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⁎ Corresponding author. INSERM, U.888, Hôpital la Colombière, Pav.42 Calixte Cavalier, 39 av. Charles Flahault, BP 34493, 34093, Montpellier Cedex 5, France. Tel.: +33 4 99 61 45
60; fax: +33 4 99 61 45 79.
E-mail addresses: d.m.davydov@gmail.com (D.M. Davydov), Robert.Stewart@kcl.ac.uk (R. Stewart), karen.ritchie@inserm.fr (K. Ritchie), isabelle.chaudieu@inserm.fr
(I. Chaudieu).
1
Tel.: +44 20 7848 0136; fax: +44 20 7848 5450.
2
Tel.: +33 4 99 61 45 60; fax: +33 4 99 61 45 79.
0272-7358/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2010.03.003
480
D.M. Davydov et al. / Clinical Psychology Review 30 (2010) 479–495
9.
Declaration of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction
The theoretical relationship between disorder and good health
has been extensively discussed in relation to somatic health in terms
of both treatment and prophylaxis (prevention, protection, and
resistance); however, these issues have received substantially less
attention in relation to mental health within both monocausal (biomedical, psychological, or sociocultural) and multi-causal
(biopsychosocial) models of psychopathology (Adler, 2009; BorrellCarrió, Suchman, & Epstein, 2004; Ghaemi, 2009; Kiesler, 1999).
Although terminology relating to somatic disorders, such as trauma
and stress, are now commonly used in mental health research and
clinical practice, other positive concepts such as immune prophylaxis
(Cooreman, Leroux-Roels, & Paulij, 2001) and hygiene (Yazdanbakhsh,
Kremsner, & van Ree, 2002), although also potentially meaningful in
relation to mental health, have not been considered. Only recently has
the possibility of an immunity model been accepted in relation to
mental well-being, but in terms of resilience (Bonanno, 2004),
meaning more than simply the absence of disorder. Although this
approach involves the identification of inherent and acquired clinical,
biological and environmental characteristics which safe-guard
mental health in the face of exposure to risk factors (Hoge, Austin, &
Pollack, 2007; Patel & Goodman, 2007) until recently it has been
conceptualized mainly in terms of mono-causal models, i.e., separately
in biomedical, psychological, or sociocultural domains of resilience,
without any attempt to integrate these within a general theoretical
framework.
Mono-causal models of psychopathology continue to be popular in
clinical practice due to their simplicity in terms of theoretical,
therapeutic and disorder prevention approaches (e.g., purely a
cognitive, behavioural, or emotion model in psychological assessment, psychotherapy research, teaching, and consultation), ignoring
moderating, mediating and confounding effects of other biosocial
variables. Mono-causal theories therefore may lose sight of the multicausal nature of human health — from genes to cultures with
developmental process mediating. Thus, we aimed to introduce a
theoretical construct rather than eclecticism, for the integration of
multiple mechanisms into a single framework applicable to any
mental health problem (Norcross & Goldfried, 2005). In this review
we seek to demonstrate that the construct of mental resilience can
provide a means of integrating social and natural sciences taking into
account both psychosocial and biological models of mental health
pathways.
While somatic disease, trauma and chronic stress are known to be
common precedents of psychiatric disorder, epidemiological studies
have found that in fact the majority of people who experience such
stressful events do not develop psychopathology, raising the question
of which resilience factors provide such mental ‘immunity’ (Collishaw
et al., 2007; Jin et al., 2009; Patel & Goodman, 2007). Historically the
general notion of protective factors for mental health dates back to the
19th century notion of mental hygiene defined as ‘the art of
preserving the mind against all incidents and influences calculated
to deteriorate its qualities, impair its energies, or derange its
movements’ and including ‘the management of the bodily powers in
regard to exercise, rest, food, clothing and climate, the laws of
breeding, the government of the passions, the sympathy with current
emotions …’ (Rossi, 1962). Concepts of ‘mental immunity’, ‘mental
hygiene’ or ‘mental resilience’ have in common the aim of broadening
research concepts in mental health beyond risk factors for pathology
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to include wellness enhancement and health promoting factors, in the
same way that it has been important to identify the characteristics of
infection-resistant groups during epidemics. Subsequently a number
of studies have underlined the importance of good mental functioning
(rather than the absence of disorder) in determining quality of life,
cognitive capacity, physical health and social productivity (Huppert,
2005; Linley & Joseph, 2004).
Our aim in this article is to review research on mental health
protection, first considering the current concepts of mental resilience,
then discussing mental health protection and resilience as integrating
(multi-level biopsychosocial) constructs, comparing these with the
semiotics and constructs of the somatic multi-level protection and
immunity models. We demonstrate that the resilience concept in
mental health research is currently hindered by the lack of a unified
methodology and poor concept definition. Our underlying assumption
has been that some other conceptual models such as multi-level
protection, which have been developed for understanding resistance
to some somatic disorders, might help the understanding of resilience
to mental disorder. We attempt to compare some of the findings from,
and definitions used, in mental resilience studies with the somatic
immunity approach to consider whether mental health research can
benefit from parallels in advances in the development of the
‘immunity’ framework. We do not propose that somatic immune
and mental resilience systems are equivalent in low-level aspects of
their relation to health disturbance. We consider ‘immunity’ as a
general term for the state of being insusceptible or resistant to a
specific threat to wellbeing, which was captured first by somatic
medicine and by the legal system, but has been largely left unclaimed
by mental health researchers. Theoretical construct of immunity in
relation to somatic health has substantially evolved over time. Mental
health scientists have on the other hand only recently accepted and
extended the term ‘resilience’ as a theoretical construct of mental
health protection, promotion and recovery processes; this term being
originally used to describe the capacity of a material or system to
return to equilibrium after a displacement. However, despite its
metaphorical origin, resilience is now referred to in mental health
science independently of its original context.
We propose that a comparison of two similar theoretical concepts
of health protection (somatic ‘immune’ and mental ‘resilience’)
will help to resolve two main challenges in mental health studies:
(i) integration of different domains of the resilience construct (i.e.
mental health protection, promotion and recovery) in one multi-level
interacting system and (ii) merging theoretical models with an
operational (resilience measurement) approach. So far, these theoretical and practical issues have been very poorly linked together and
resilience has mainly been measured according to specific operational
definitions depending on the aims of individual studies or according
to predefined indicators relating to the theoretical position of an
inventory's author (Kaufman, Cook, Arny, Jones, & Pittinsky, 1994;
Vaishnavi, Connor, & Davidson, 2007). These hamper meta-analysis of
findings across resilience studies and challenges in resilience research
may be principally explained by defects in operationalization
stemming from the absence of a common theoretical model. We
consider that extrapolation from a somatic immunity approach to
mental health is in accordance with George Engel's biopsychosocial
model of health in general without the distinctions it draws between
somatic and mental domains (Ghaemi, 2009). In a practical sense the
immunity model proposes that each level of resilience can be
employed to protect an individual's mental health more or less
D.M. Davydov et al. / Clinical Psychology Review 30 (2010) 479–495
effectively depending on the condition in question, analogous to
pluralistic models in psychiatry like Jaspers' methodological pluralism
(Ghaemi, 2007) and Adler's approach of high and low system levels
integration in biopsychosocial models (Adler, 2009).
In this review we also (i) explore potential biological, behavioural
and social mechanisms conferring resilience, (ii) classify resilience
research both by levels (individual and group) and by approaches
(harm-reduction, health protection and promotion), (iii) critically
examine measurements of resilience, (iv) offer a group of adaptive
reactivity indicators as common measures of resilience affected at
different levels and by different mechanisms, and (v) suggest some
challenges for future resilience research. Our general aim is to advance
theoretical conceptualizations of resilience towards the resolution of
conceptual inconsistency and hence facilitate its measurement.
2. Current conceptualizations of resilience
The now widely-used concept of resilience, derived from both the
social and health sciences (Tusaie & Dyer, 2004) has often been
criticized (Earvolino-Ramirez, 2007; Luthar, Cicchetti, & Becker, 2000;
Vanderbilt-Adriance & Shaw, 2008) due to ambiguities in both
definitions and terminology, heterogeneity in the level and type
(e.g. ‘personal meaning’) of risk or stress experienced for someone to
be termed ‘resilient’ and in the competence required by individuals in
order to be qualified as such. Together these criticisms have cast doubt
on the utility of resilience as a theoretical construct. For example,
some researchers have investigated resilience (or ‘resiliency’) as an
individual trait (Ong, Bergeman, Bisconti, & Wallace, 2006) or an
epiphenomenon of adaptive temperament (Wachs, 2006). In some
studies (Fredrickson, Tugade, Waugh, & Larkin, 2003) habitual
effective coping as a durable personal resource is considered to
constitute a facet of trait resilience, which functions as a reserve that
can be drawn on as a buffer against a wide range of future adversities.
Positive emotions are seen as active ingredients within trait resilience,
which reduce the risk of depression and promote thriving (Fredrickson et al., 2003). In other studies, emotional resilience has been used
as a concept to imply the flexible use of emotional resources for
adapting to adversity (Waugh, Fredrickson, & Taylor, 2008) or as the
process linking resources (adaptive capacities) to outcomes (adaptation) (Norris, Stevens, Pfefferbaum, Wyche, & Pfefferbaum, 2008).
Researchers using this concept view resilience as a process or force
that drives a person to grow through adversity and disruption
(Jacelon, 1997; Richardson, 2002; Richardson & Waite, 2002). The
resilience may vary according to age (e.g. suggested to decrease over
70 years, Rothermund & Brandtstädter, 2003), with modifications
occurring throughout the lifespan at both individual and cultural
levels (Connor & Zhang, 2006; Gillespie, Chaboyer, & Wallis, 2007;
Hegney et al., 2007). Overall these definitions are ambiguous and
difficult to operationalize for measurement purposes.
On the other hand the numerous studies of determinants of
resilience have been quite specific (Cameron, Ungar, & Liebenberg,
2007; Connor & Zhang, 2006; Norris et al., 2008) including genetic,
biological, psychological, family, community, social, and environmental effects, which may interact during exposure to particular
environmental hazards. Resilience has been investigated as a function
of environmentally determined individual development (e.g. social or
ethnic group) and also as a result of genetic factors (Cameron et al.,
2007). For example, shared family and unique environmental effects
have been reported to account for the variance in perceived severity of
daily stressors (Charles & Almeida, 2007) which is in turn a
determinant of resilience (Stawski, Sliwinski, Almeida, & Smyth,
2008). In addition, the influence of a unique environment on
perceived stress has been observed to exert a stronger influence on
older adults irrespective of gender (Charles & Almeida, 2007). Gender
has, however, been observed to modulate genetic effects. For example,
a meta-analysis relating to brain-derived neurotrophic factor (BDNF)
481
Val66Met polymorphism found significant resilient (protective)
effects against depression in men, but not in women (Verhagen
et al., 2010).
A range of studies have suggested that ‘resilience’ can be seen as
synonymous with reduced ‘vulnerability’ (Hofer, 2006; Schneiderman,
Ironson, & Siegel, 2005), with ability to adapt to adversity (Cameron
et al., 2007; Kim-Cohen, 2007; Stanton, Revenson, & Tennen, 2007) or
‘cope’ (Skinner & Zimmer-Gembeck, 2007; Taylor & Stanton, 2007).
Such studies implicate various adaptive systems as explanations of
resilience, focusing on processes acting at multiple levels from
childhood to old age, which promote and protect human development
across the lifespan (Carrey & Ungar, 2007; Lerner, 2006; Masten &
Obradovic, 2006).
At a conceptual level it is important to distinguish mechanisms:
(i) against aversive or stressful events themselves (often defined as a
resistance), (ii) against adverse outcome in terms of transformation of
adaptive responses and health-promotion processes to maladaptive
(defective) ones (i.e., persistent dysfunction), and (iii) against
development of a disorder (psychopathology) in the face of aversive
events. The first domain of resilience may be defined as non-adaptive
types of protection at an individual level due to resources (adaptive
capacities) taken from external levels (e.g., society) and may be
attributed to the mental health protection system (Fig. 1 and Table 1).
The last two domains of resilience may belong to the same dimension
(the adaptive type of protection of a person), but may be explored
from different perspectives on human health and its disturbance and
may be attributed to the mental health resilience system itself (Fig. 1
and Table 1). According to one definition, the healthy condition is
related to the development of a phenotype of reactivity to
environmental challenges which may be adaptive or maladaptive
depending on the context (Ellis & Boyce, 2008), but may also be
viewed in terms of the traditional nosological or biomedical
conception of health.
Thus, understanding resilience is important as a means of
developing interventions to prevent and/or treat common mental
disorders whose risk factors have high individual and cultural
variability in impact, notably anxiety, depression, and stress reactions
(Connor & Zhang, 2006). However, although the mental health
protection approach has benefited from empirical research, potential
deficiencies in its central terminology have inhibited further conceptual development. A broad systems approach, inferring the capacity of
dynamic systems to withstand or recover from significant disturbance
Fig. 1. Supplementary to Table 1, a general schema of interaction (crosses), feed forward
(thin arrows) and backward (thick arrows) effects within and between suggested levels,
mechanisms and their components (biological, psychological, micro- and macro-social
factors; presented in grey) within a ‘Mental Health Protection’ framework.
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D.M. Davydov et al. / Clinical Psychology Review 30 (2010) 479–495
Table 1
Cross-reference of somatic health protection and mental resilience systems, defending against disease by identifying and neutralizing adversities/pathogens on different layers/
levels (a general schema of interrelations within and between suggested levels and factors (mechanisms) related to mental health cells is provided in Fig. 1; examples of studies
related to mental health cells are provided in Table 2).
General health protection system
Somatic health protection system
Mental health protection system
External layers/levels
Natural
(subject-related factors)
Artificial
(society-related factors)
Natural
(subject-related factors and experience)
Artificial
(received from society)
Non-specific to adversity/
pathogen barriersa
Adaptive or specific to adversity/
pathogen barriersb
Quality of received surface physical
and chemical barriers (e.g. skin)
Proximity to infectious agent
Quality of received sanitary
barriers (e.g. soap)
Quality of sanitary barriers
(e.g. specific food control)
Quality of received interpersonal
relationships
Quality of perceived social
support
Quality of general national,
economical and cultural barriers
Quality of targeted assistance
acquired from society
General immunity
Immune system
Mental resilience system
Internal layers/levels
Natural
(subject-related factors)
Artificial
(society-related factors)
Natural
(subject-related factors and experience)
Artificial (received from society)
Non-specific to adversity/
pathogen barriersa
Inflammation response
National ‘fortification’
programs (e.g. vitamin
enrichment)
Phenotype advantages
‘Fortification’ programs for general
regulation of behaviour or organism
functioning in a community
Passive immunization
Imprinting, implicit learning
Immunological memory
related to active
immunization by vaccines
Epigenetic and meaning change
mechanisms related to real life
adversities (principal in childhood)
Externally imposed regulation of
emotions and behaviours in a person
Cognitive reappraisals related
to cognitive therapy
Adaptive or specific to adversity/pathogen barriersb
Passive barrier after
Passive (maternal)
resilience/antibody transferc
immunity after birth
Active (acquired) barrier after
Infection-related
adversity/antigen-presentationd
immunological memory
(principal in childhood)
a
The defence barrier, which leads to immediate maximal response to any adversity/pathogen.
The defence barrier, which helps to adapt to recognized (specific) adversity/pathogens more efficiently.
The fast, but short-lasting defence barrier with resilience/antibody elements which were externally developed and transferred to a person for protection against a specific
adversity/pathogen.
d
The late, but long-lasting defence barrier with resilience/antibody elements which were internally developed with a lag time between exposure and maximal response for
protection against a specific adversity/pathogen after its recognition (identification) by the defence system.
b
c
(Masten, 2007) has more recently been proposed as being potentially
more relevant. Such a biopsychosocial model of resilience assumes the
existence of multiple processes within and outside an organism
protecting against disturbance in a manner similar to the complex
model of somatic health protection system.
3. A biopsychosocial (multi-level) construct for mental resilience
This approach assumes firstly that, in order to survive a
psychological challenge, the system should have in-built mechanisms
able to recognize and neutralize adversities and their related effects.
As with somatic immunity against a specific pathogen, these resilience
mechanisms may be innate, or may have been developed: naturally
through individual adaptation, or artificially through external influences such as public health activities (Tables 1 and 2). The
mechanisms may engage individual resources actively or passively,
may be independent with respect to each other, may interact, or may
constitute a causal chain (see Fig. 1). They may serve to protect and/or
promote mental health, accelerate recovery and/or mitigate the
negative effects of mental ‘pathogens’ — i.e. stressors (see Fig. 2). This
approach refers to (i) ‘harm-reduction’ factors which can operate in
the face of risk factors which may themselves be difficult to modify
(such as genetic risk factors or poverty); (ii) protective factors which
decrease the probability of pathology, and (iii) promotion factors
which actively enhance positive psychological well-being (Hoge et al.,
2007; Patel & Goodman, 2007).
Through evolution, biological organisms have developed various
adaptive and defensive systems to survive and cope successfully with
stressors. According to the ‘law of parsimony’ a general operational
principle is that these systems should be similar. For example,
analogous to somatic health protection (e.g., the somatic immune and
hygiene systems), the mental resilience system is likely to protect
against adversities through multi-level defence mechanisms of
varying specificity in terms of the stressor and/or subject in question
(see Table 1). Non-specific mechanisms may include, for example,
geographical, political, economic, social, medical and cultural barriers
modifying the effects of a variety of risk factors such as bereavement,
disability, unemployment, and poverty. Breaching these barriers (e.g.,
see discussion below relating to the collapse of the Soviet Union,
Nepomnyashchiy & Davydov, 2007) may give rise in turn to an
immediate non-specific defence response by the individual, either
withdrawal (freeze — isolation or flight — immigration, escape), or
engagement (fight — strike, attack) depending on individual
physiological arousal conditions (Davydov, Shapiro, Goldstein, &
Chicz-DeMet, 2005; Davydov, Shapiro, Goldstein, & Chicz-DeMet,
2007). Adversity penetrating this non-specific individual defence
barrier may generate a third level of reactivity at an individual level
(e.g., different avoidance and approach coping strategies). If successful this specific (adaptive) response is retained in individual memory
(as a process of ‘behavioural immunization’, Seligman & Maier, 1967)
allowing the resilience system to mount faster and stronger attacks
next time this specific adversity is encountered. The effectiveness of
both non-specific and adaptive (specific) resilience barriers depends
on the ability of the system to distinguish between adversities and
advantages at both a group and individual level. As with promotion
approaches for improving somatic health (e.g. prophylactic immunization) the model assumes multiple levels of adjustment combining
external (passive immunization) and internal (active immunization)
resources to enhance mental health in advance against possible future
adversities (see Tables 1 and 2).
However, within a somatic immune system some normal defence
strategies (such as inflammation) may themselves become handicapping (e.g., hypersensitivity or auto-immunity). In the case of mental
health, this might involve outcomes such as dependence on external rewards (e.g. financial support from the state), phobias or
physiological vulnerability (e.g. chronically raised cortisol levels).
Other examples of such trade-offs in somatic health are protection
mechanisms such as fever, diarrhoea and vomiting, which can be
D.M. Davydov et al. / Clinical Psychology Review 30 (2010) 479–495
483
Table 2
Supplementary to Table 1, specific examples of resilience within a ‘Mental Health Protection’ framework.
Mental health protection system
External layers/levels
Non-specific to adversity barriersa
b
Adaptive or specific to adversity barriers
Natural
(subject-related factors and experience)
Artificial
(received from society)
Potential interpersonal relations providing a balance of ‘positive experience’
and ‘behavioural immunization’ in childhood (Ellis & Boyce, 2008)
Perceived availability and quality of potential social support against
posttraumatic distress (Regehr, Hemsworth, & Hill, 2001)
National barriers against political violence
(e.g., the Israel–Lebanon border, Norris et al., 2008)
Targeted assistance acquired from society for people
with psychiatric disabilities (Hutchinson et al., 2006)
Mental resilience system
Internal layers/levels
Natural
(subject-related factors and experience,
temperament or phenotype constructs)
Artificial
(received from society)
Non-specific to adversity barriersa
Phenotype advantages related to stress reactivity
and modulated by hormonal, autonomic and central
neurotransmitter balance (Davydov, Shapiro,
Goldstein, et al., 2007; Davydov et al., in press,
Feder et al., 2009; Young & Altemus, 2004)
Global mental health ‘fortification’ with vitamin
enrichment of food in national nutrition programs
(Alpert et al., 2000)
Adaptive or specific to adversity/pathogen barriersb
Passive barrier after resilience transferc
Imprinting and implicit learning in infants
(Schore, 2001)
Active (acquired) barrier after adversity
presentationd
Epigenetic mechanisms of acquiring stress
responsiveness (Feder et al., 2009)
Externally imposed regulation of emotions and behaviours
or modulation of emotion primarily through the efforts of
others (Eisenberg & Spinrad, 2004)
Cognitive reappraisals for being able to regulate emotion
oneself (self-regulation of emotions) (Schaal, Elbert, &
Neuner, 2009)
a, b, c, d
Idem (see Table 1).
considered as normal defences but which may become themselves the
source of health disturbance if they are not sufficiently controlled.
Another example of trade-off in relation to mental health is national
borders, a resilience (external protection) factor provided by society
(see above and in Tables 1 and 2). Borders may constitute a resilience
factor both by providing protection from external challenges or
outflow of the nation's own protective benefits. However, borders and
their associated laws may also constitute an impediment for some
persons (migrants, refugees or asylum seekers) escaping threats in
their own country and in the context of persons and societies seeking
the import of advanced ideas, creations, technologies, people and
goods for sustained development. Moreover, for some groups of
people (e.g., for quasi-nomadic people such as some businessmen,
scientists or artists whose activities demand sharing of finance,
knowledge and products of their creativity, for people with risk- or
sensation-seeking phenotype or for people living in traditional
nomadic cultures) the ability to cross borders constitutes an
important on-going resilience factor against threats for their wellbeing. For these persons border permeability may reduce threat. Some
trade-off controversies and defects in the somatic protection and
mental resilience systems associated with their dependence on
context in transformation to risk factors may have common external
(e.g., cultural) or internal (genetic, Suchankova et al., 2009)
determinants. Thus, potential adverse effects of a resilience system
should also be considered. Subsequently most of the resilience factors
summarized in Tables 1 and 2, Fig. 1 and elsewhere in the text should
also be considered in terms of their context (i.e., dependence on
‘quality’ or presentation of other biopsychosocial resilience or risk
factors) with a possible trade-off between their resilience and risk
effects on mental health.
3.1. Individual level of resilience
Individual-level resilience requires individual non-specific and
specific-to-adversity ‘natural immune’ resources to confer resilience
(see Tables 1 and 2, Fig. 1). These mechanisms are the focus of studies
of why some individuals who are exposed to known risk factors, do
not develop mental health problems. This approach has provided
insights into resilience in the same way that somatic studies have
investigated commercial sex workers who have not contracted HIV/
AIDS (Kaul et al., 2000; Rowland-Jones et al., 1998), or cancer
survivors who have exceeded their life expectancies (Gotay, Isaacs, &
Pagano, 2004). In the mental health domain such ‘high-exposure’
studies have included patients awaiting cardiac surgery with
resilience to anxiety-related heart rate hyperactivation (Bokeriia,
Golukhova, Polunina, Davydov, & Kruglova, 2008), people after
bereavement with resilience to chronic grief (Bonanno et al., 2002),
and other examples of individuals retaining a positive outlook in
difficult circumstances (Becoña, 2007; Felten & Hall, 2001; Jones,
2006; Windle, Markland & Woods, 2008). Some individuals have been
shown to benefit from resilience-promoting interventions such as
stress-management and stress-prevention (Steinhardt & Dolbier,
2008). Moreover, aspects of mental health resilience (such as positive
affect, positive expectancy regarding health outcomes, finding
meaning in challenging circumstances) may also assist in maintaining
somatic well-being (Ickovics et al., 2006). Some somatic immune
mechanisms (e.g., cytokines) may have a direct promoting influence
on internal mental resilience barriers (Goldstein, Kemp, Soczynska, &
McIntyre, 2009; Miller, 2009). The adaptive somatic immune system involving immunological memory to self-antigens (e.g. memory
T-cells to CNS-related antigens) has been suggested to be involved in
the so-called ‘behavioural immunization’ mechanism of mental
resilience (Lewitus & Schwartz, 2009). Moreover, immunization
with CNS-related antigens as a means of protecting against depression
has recently been introduced (Lewitus et al., 2009).
3.2. Group level of resilience
Group-level factors can be imposed on an individual by external
resources (geographical, national, cultural, community or social)
analogous to social hygiene or herd immunity in somatic health (see
Tables 1 and 2, Fig. 1). For example, folic acid fortification of all
enriched grain products in the United States, an intervention at a
national level to reduce the risk of neural tube birth defects in
newborns, has been suggested to have an additional effect of
improving and promoting mood because higher serum folate levels
are associated with better mood in at-risk groups and may play a
protective role against depression among specifically predisposed
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Fig. 2. Model of three Mental Resilience System mechanisms (health protection,
promotion and harm-reduction) in the face of aversive events (i.e., stressors with
various power): before, during and after a health disturbance.3
individuals (Alpert, Mischoulon, Nierenberg, & Fava, 2000). Another
proposed example are omega-3 fatty acid fortification programs,
which may have both harm-reduction and health-promotion effects
for mental health (Freeman et al., 2006; Harris, 2007; Hibbeln,
Ferguson & Blasbalg, 2006; Lin & Su, 2007; McNamara et al., 2009).
Some advantages of group-level protective factors have been received
by individuals through education and employment laws which for
example protect children from child labour, and which have the
potential to be further developed if schools and local communities
become able to screen for abuse. However, some group factors
favouring protection against some challenges may be detrimental for
others. For example, lipid-lowering recommendations in many
Western countries protecting against cardiovascular diseases has
been suggested to inactivate a biological component of the resilience
system against adverse psychological and behavioural problems in
some persons (Troisi, 2009).
The group factors may account, at least in part, for variations in
prevalence of mental disorders between different populations: for
example between countries or between migrant and non-migrant
groups. For example, two population-based surveys in Great Britain
found a 3-fold lower prevalence of child mental disorder among
populations of Indian origin (Green, McGinnity, Meltzer, Ford, &
Goodman, 2005; Meltzer, Gatward, Goodman, & Ford, 2000), raising
the possibility of a group-level resilience mechanism in the context of
an overall decline in child mental health in Britain in recent years
(Collishaw, Maughan, Goodman, & Pickles, 2004; Rutter & Smith,
1995). Another related finding is a relatively low rate of suicide in
older men of South Asian ancestry in Britain (England and Wales) and
across the world compared to peers of other origins (McKenzie, Bhui,
Nanchahal, & Blizard, 2008). Furthermore, the World Mental Health
Survey found some of the lowest prevalences of disorder in some of
the poorest and most disadvantaged populations in the world —
populations in which well-established individual-level risk factors
3
In the present schema, capacity and changes in the Mental Resilience System are
indexed by systolic blood pressure reactivity (Δ SBP) to challenges (arousal versus
relaxed), which is positively associated with level of daily positive affect, but health
disturbance is indexed by diastolic blood pressure reactivity (Δ DBP) to challenges
(arousal versus relaxed), which is positively associated with level of daily negative
affect (according to Davydov et al., in press; Davydov & Ritchie, 2009; Phillips et al.,
2009). Time scale is individual and may be related to minutes, hours, days, months,
and years of specific person–environment interactions conferring neutral, risk or
resilience effects. Promotion gain (‘promo gain’) may be related to (i) stressor-specific
(i.e., wider protection indexed by gain of a number of specific stressors covered) or (ii)
stressor-non-specific (i.e., more powerful protection, e.g., indexed by SBP reactivity
gain) increase in health protection aspect of resilience. The SBP and DBP reactivity
scales are presented according to average population means and are not specified in
relation to low or high reactivity phenotypes.
such as acute economic difficulties, poor housing and low education
are widespread (Demyttenaere et al., 2004). Several authors have
stressed the need for resilience research to include ecological analyses
as there is likely to be variability in the effects of individual-level
resilience factors between different populations and cultures (Diener,
Oishi, & Lucas, 2003; Haeffel & Grigorenko, 2007). However, a
substantial challenge is of course the wide variety of cultural and
linguistic differences in conceptions and meanings of mental health.
Another challenge is to distinguish whether a particular group-level
effect is related to a specific cultural factor or social context
(externally provided for individuals), or to a genetic resilience
resource (internally retrieved by individuals) in ethnically homogeneous groups (McCormick et al., 2009; Voracek & Loibl, 2008;
Wiltermuth & Heath, 2009): for example Japanese women experiencing relatively few physical and emotional symptoms in the perimenopausal period (Steiner, Dunn, & Born, 2003). It has thus been
proposed that these findings may not only indicate cultural
differences but also may reflect the influence of biological, genetic
and nutritional/dietary factors (Lock, 1994; Nagata, Takatsuka, Inaba,
Kawakami, & Shimizu, 1998).
4. Resilience approaches in mental health research
4.1. The harm-reduction approach (Fig. 2)
Some researchers describe mental resilience in terms of quick and
effective recovery after stress (Tugade & Fredrickson, 2004). This
parallels somatic recovery mechanisms after pathogen invasion
through external and internal protective barriers, and describes the
ability to ‘spring back’ to initial levels of mental, emotional and
cognitive activity after an adversity (such as functional limitation,
bereavement, marital separation, or poverty). The ‘pathogen invasion’
construct implies that both cognitive appraisal of an event and the
emotions induced by the event are perceived by the individual as
negative or stressful (Davydov, Zech, & Luminet, 2008), i.e., an event
acquires a personal meaning, which can be semiotically designated as
a sign (Adler, 2009). In some cases this aspect of resilience is
operationalized as a general health score that, despite deterioration
after exposure to adversity, subsequently returns to pre-exposure
levels. The prevalence of this kind of resilience has been estimated in
community studies to be about 15%: highest in older women and
increased by 40–60% in the presence of high social support before and
during adversity (Netuveli, Wiggins, Montgomery, Hildon, & Blane,
2008). Other researchers argue that harm-reduction or recovery
mechanisms of resilience should be distinguished from mechanisms
of protection or resistance against harmful effects of adversity, which
may be associated with different underlying neurobiological processes (Yehuda & Flory, 2007).
4.2. The protection approach (Fig. 2)
In other studies, mental resilience is described in terms of
protection mechanisms (analogous to ‘immune barriers’), which
help to preserve a given measure of health in the face of adversity
(Patel & Goodman, 2007). For example, in a national community study
of adults with chronic pain using the Profile of Chronic Pain Screen, a
sub-sample with this kind of resilience was identified who had high
scores (at least 1 SD above the mean) on a severity scale combined
with low scores (at least 1 SD below the mean) on scales assessing
interference and emotional burden (Karoly & Ruehlman, 2006). An
age- and gender-matched non-resilient sub-sample was then selected
with high scores (at least 1 SD above the mean) on all three scales.
Different specific factors may be related to this type of resilience at
multiple (e.g., individual and group: family, peer group, school and
neighbourhood) levels (Jessor, Turbin, & Costa, 2003). For instance, in
two epidemiological studies resilience in adults who had experienced
D.M. Davydov et al. / Clinical Psychology Review 30 (2010) 479–495
early adversity was associated with higher quality of interpersonal
relationships in adolescence and adulthood (Collishaw et al., 2007;
Quinton, Rutter, & Liddle, 1984; Rutter & Quinton, 1984).
4.3. The promotion approach (Fig. 2)
Some researchers have associated the concept of resilience with
promotion of mental health (Ong et al., 2006; Patel & Goodman,
2007). This approach focuses on the development of additional
resources, which can be used (applied for) by harm-reduction and
protection mechanisms (analogous to pre-immunization or a general
strengthening of the immune system), but has been mainly associated
with high individual levels of positive experience (Fredrickson, 2004;
Fredrickson & Joiner, 2002). For example, the Isle of Wight study
found that the maintenance of mental health in adulthood despite
substantially higher levels of psychosocial stressors (e.g. criminality
and worse relationship quality) could be explained by the absence of
early physical or sexual abuse, which was hypothesized to promote in
turn positive psychological well-being as a resilient barrier against
later adversity (Collishaw et al., 2007). A meta-analysis concluded
that the occurrence of daily positive emotions serves to moderate
stress reactivity and mediate stress recovery and that differences in
this kind of psychological resilience account for meaningful variation
in daily emotional responses to stress (Ong et al., 2006). Higher levels
of this kind of resilience predict a weaker association between
positive and negative emotions, particularly on days characterized by
heightened stress. Over time, the experience of positive emotions
functions to assist high-resilience individuals in their ability to
recover effectively from daily stress. This type of resilience mechanism is not restricted to the individual level but can also be considered
to be the result of a variety of external (e.g., community and cultural)
factors. Indeed, some social resilience mechanisms such as religion are
commonly associated with positive emotions.
However, in studies of mental health promotion, the ‘positive
experience’ mechanism underlying anti-stress fortification (i.e. presence
of fewer adversities in past and/or more positive events) can be
contrasted to a ‘behavioural immunization’ (analogous to vaccination)
mechanism underlying anti-stress training (i.e. relating to memory of
past negative experience). In contrast to ‘positive experience’, ‘behavioural immunization or immunomodulation’ promotes mental resilience through exposure to a transitory stressful event, which is
successfully overcome; this exposure may be delivered to a person
either naturally (i.e. during everyday life) or artificially (e.g. by a
behavioural training programme) (see Tables 1 and 2). For example,
experienced survivors of floods were found to exhibit lower anxiety after
encounters with the same disaster compared with inexperienced
survivors (Norris & Murrell, 1988). These two mechanisms may promote
resilience differently: (i) by increasing protection in a manner which is
not specific to the index stressor (indexed by a reactivity capacity) or
(ii) by increase of a stressor-specific protection indexed by a wider
number of specific stressors (see discussion below and Fig. 2).
In the psychology of positive mental states, this ‘anti-stress
training’ phenomenon has been contrasted to a process of simple
recovery or the return to prior (pre-trauma) baseline states (i.e.,
homeostasis) and described as thriving or ‘going beyond the previous
baseline to grow and even flourish’ (Joseph & Linley, 2006, p. 1043).
This theory proposes that simple recovery after stress still leaves a
person at increased vulnerability to a similar adversity. However,
underlying mechanisms and instruments for assessing such phenomena as ‘thriving’ and reorganization of functioning have not been wellcharacterized (Frazier et al., 2009). The ‘behavioural immunization’
approach on the other hand proposes that positive changes following
adversity are related to a return from mental disorganization to a
healthy baseline (homeostasis), with resilience conferred by new
positively accommodated experience (memory). This new experience
results in a more flexible regulation system for maintaining
485
homeostasis and mentally healthy functioning within a wider range
of stressful events (i.e. resistance to more ‘strains’ of mental
‘pathogens’) compared to the pre-trauma period (Fig. 2). This
extension of ‘living space’ associated with mentally healthy functioning or mental resilience is therefore the result of adverse experiences,
which a person after adversity may benefit from and which can be
assessed in everyday life by psychophysiological instruments (see,
e.g., Davydov, Shapiro, & Goldstein, in press).
As with somatic immunity these two promotion mechanisms
(anti-stress fortification and training) may have dose–response
relationships in terms of conferring resilience. For example, living in
a psychologically sterile environment (absence of any past adversity)
can result in reduced individual resilience to even moderate stressful
events because of decreased tolerance (analogous to theories of
hypersensitive immune responses). On the other hand, an extremely
stressful experience (unresolved or chronic stress) can also lead to
poor individual resilience to future adversities through increased
tolerance (analogous to immune deficit hyposensitivity mechanisms).
Taken together, these theories propose that effective mental resilience
requires an individual homeostatic balance between negative and
positive experiences, just as immune activation and suppression are
proposed to balance in the modern hygiene hypothesis (Yazdanbakhsh et al., 2002; this is discussed further under Challenge 1). This
approach has been elaborated under a framework of the homeostatic
hypothesis of emotion regulation by a general arousal manipulation
(Davydov, Lavrova, & Drozdov, 2005; Davydov, Shapiro, Goldstein
et al., 2007; Davydov, Shapiro, et al., 2005). The homeostatic concept
hypothesizes that a balance between negative and positive experience
in everyday life is essential for mental health in the individual, and
may be maintained by different circadian physiological mechanisms
regulated through baroreflex pathways (Davydov et al., in press).
5. Some potential multi-level mechanisms conferring resilience
5.1. Genetic, epigenetic and gene–environment mechanisms
The individual- and group-level approaches include the relevance
of gene–environment interactions to resilience against mental
disorders. Gene–environment interactions involving exogenous and
endogenous environmental factors are known to shape behaviour and
personality development (Schmidt, Fox, Perez-Edgar, Hamer, 2009).
The genetic effects are now thought to influence person–environment
interactions (reactivity phenotypes) rather than rigidly define
psychopathological phenotypes (Wichers et al., 2007a).
Meta-analyses of gene–environment interactions (Munafò, Durrant,
Lewis, & Flint, 2009) suggest that deficient knowledge of the type
of interaction between specific genes and specific challenges (e.g.
synergism, antagonism, and crossover) limits understanding of how
a given interaction operates with respect to a specific reactivity
phenotype in particular context (i.e. whether adaptive or maladaptive).
For example, human fMRI studies sugges...
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