The resilience handbook approach to stress and trauma

The ventral corticolimbic pathways have specialized in Table P.1 Summary of Resilience as an Adaptive Process and Resilience Interventions Initiation Intrapersonal Interpersonal Social

The Resilience Handbook

How are people and communities able to prevail despite challenge? What helps them bounce back from adversity and even grow in knowledge and understanding? And can this resilience

be taught? During the past decade, exciting scientific advances have shed light on how

resil-ience operates from neurons to neighborhoods In The Resilresil-ience Handbook, experts in the

science of resilience draw on human and animal research to describe the process of resilience and follow its course as it unfolds both within individuals and in social networks Contribu-tors also highlight the promise of new interventions that apply what we know about resil-ience processes to bolster positive health, and raise some of the pressing questions and issues for the field as it matures

This handbook is designed to be used by students as an invitation to a burgeoning field;

by researchers, as a framework for advancing theories, hypotheses, and empirical tests of resilience functions; and by clinicians, as a comprehensive and up-to-the-minute integration

of theory and practice

Martha Kent is a research scientist at the Phoenix VA Health Care System and a member of the Resilience Solutions Group at Arizona State University

Mary C Davis is a professor in the department of psychology at Arizona State University and a member of the Resilience Solutions Group

John W Reich is an emeritus professor of psychology at Arizona State University and the

coeditor of the Handbook of Adult Resilience.

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The Resilience Handbook

Approaches to Stress and Trauma

Edited by

Martha Kent, Mary C Davis,

and John W Reich

First published 2014

by Routledge

711 Third Avenue, New York, NY 10017

Simultaneously published in the UK

by Routledge

27 Church Road, Hove, East Sussex BN3 2FA

© 2014 Taylor & Francis

Routledge is an imprint of the Taylor & Francis Group, an informa business

The right of the editors to be identified as the author of the editorial material,

and of the authors for their individual chapters, has been asserted in accordance

with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved No part of this book may be reprinted or reproduced

or utilised in any form or by any electronic, mechanical, or other means,

now known or hereafter invented, including photocopying and recording,

or in any information storage or retrieval system, without permission in

writing from the publishers.

Trademark notice: Product or corporate names may be trademarks or

registered trademarks, and are used only for identification and

explanation without intent to infringe.

Library of Congress Cataloging in Publication Data

The resilience handbook : approaches to stress and trauma / edited by Martha Kent,

Mary C Davis, and John W Reich.

pages cm

Includes bibliographical references and index.

1 Resilience (Personality trait) 2 Stress (Psychology) I Kent, Martha

(Research scientist) II Davis, Mary C editor of compilation

III Reich, John W., 1937- editor of compilation

Part A: Resilience as Biobehavioral Adaptation

1 Seeking and Loss in the Ancestral Genesis of Resilience, Depression,

JAAK PANKSEPP

2 The Roles of Predictive and Reactive Biobehavioral Programs in

Resilience 15

MATTIE TOPS, PHAN LUU, MAARTEN A S BOKSEM, AND DON M TUCKER

3 Approach/Engagement and Withdrawal/Defense as Basic Biobehavioral

MARTHA KENT

GRETA B RAGLAN AND JAY SCHULKIN

5 The Automatic Basis of Resilience: Adaptive Regulation of Affect

SUSANNE SCHWAGER AND KLAUS ROTHERMUND

6 The Regulatory Power of Positive Emotions in Stress: A

CHRISTIAN E WAUGH

7 Responding to Trauma and Loss: An Emotion Regulation Perspective 86

MATTHEW TYLER BODEN, MADHUR KULKARNI, ASHLEY SHURICK,

MARCEL O BONN-MILLER, AND JAMES J GROSS

DONALD A HODGES

9 Oxytocin and Attachment Facilitate a Shift From Seeking Novelty

to Recognizing and Preferring Familiarity: The Key to Increasing

Resilience? 115

MATTIE TOPS, FEMKE T A BUISMAN-PIJLMAN, AND C SUE CARTER

MARY H BURLESON AND MARY C DAVIS

GRIT HEIN

MARIO MIKULINCER AND PHILLIP R SHAVER

13 Using the Caregiver System Model to Explain the Resilience-Related

STEPHANIE L BROWN AND MORRIS A OKUN

ALEX J ZAUTRA

15 Developmental Social Factors as Promoters of Resilience in

BEKH BRADLEY, TELSIE A DAVIS, JOANNA KAYE, AND ALIZA WINGO

SECTION 2

Part A: Activating Interventions

16 Behavioral Activation as a Treatment for Depression: Theory,

GABRIEL S DICHTER, MORIA SMOSKI, ROSELINDE K HENDERSON,

AND SONA DIMIDJIAN

17 Resilience Training for Action and Agency to Stress and Trauma:

MARTHA KENT AND MARY C DAVIS

ALICIA J HOFELICH AND STEPHANIE D PRESTON

19 Forgiveness Interventions and the Promotion of Resilience Following

NATHANIEL G WADE, JERITT R TUCKER, AND MARILYN A CORNISH

CRYSTAL L PARK AND JEANNE M SLATTERY

21 The Skills Training in Affective and Interpersonal Regulation

(STAIR) Narrative Model: A Treatment Approach to Promote

Resilience 285

CHRISTINA M HASSIJA AND MARYLENE CLOITRE

22 Promoting Resilience After Trauma: Clinical Stimulation of the

JESSIE L FRIJLING, MIRJAM VAN ZUIDEN, SASKIA B J KOCH, LAURA NAWIJN, DICK J VELTMAN, AND MIRANDA OLFF

Rad-Marcel O Bonn-Miller, PhD, Center for Health Care Evaluation/Center for Excellence

in Substance Abuse Treatment and Education, Veterans Administration/Philadelphia VAMC, Menlo Park, CA/Philadelphia, PA

Bekh Bradley, PhD, Mental Health Service, Atlanta VA Medical Center, Atlanta, GA; and Department of Psychiatry and Behavioral Sciences, Emory University School of Medi-cine, Atlanta, GA

Stephanie L Brown, PhD, Department of Preventive Medicine, Stony Brook University, Stony Brook, NY; and Institute for Social Research, University of Michigan, Ann Arbor, MI

Femke T A Buisman-Pijlman, PhD, Department of Pharmacology and Department of Psychiatry, University of Adelaide, Adelaide, South Australia, Australia

Mary H Burleson, PhD, Department of Psychology, Arizona State University, Tempe, AZ

C Sue Carter, PhD, Translational Research in Neural Medicine, Research Triangle tute International, Research Triangle Park, NC

Insti-Marylene Cloitre, PhD, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA; and New York University Langone Medical Center, New York, NY

Marilyn A Cornish, MS, Department of Psychology, Iowa State University, Ames, IA

Mary C Davis, PhD, Department of Psychology, Arizona State University, Tempe, AZ

Telsie A Davis, PhD, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA

Gabriel S Dichter, PhD, UNC-Chapel Hill, Chapel Hill, NC

Sona Dimidjian, PhD, Department of Psychology, University of Colorado at Boulder, Boulder, CO

Jessie L Frijling, MS, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.

James J Gross, PhD, Department of Psychology, Stanford University, Stanford, CA

Christina M Hassija, PhD, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, CA; and Stanford University School of Medicine, Stanford, CA

Grit Hein, PhD, Laboratory for Social and Neural Systems Research, Department of nomics, University of Zurich, Zurich, Switzerland

Eco-Roselinde K Henderson, MA, Department of Psychology, University of Colorado at Boulder, Boulder, CO

Donald A Hodges, PhD, Music Research Institute, University of North Carolina at sboro, Greensboro, NC

Green-Alicia J Hofelich, PhD, Department of Psychology, Williams College, Williamstown, MA

Joanna Kaye, BA, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA

Martha Kent, PhD, Research Service, Phoenix VA Health Care System, Phoenix, AZ; and Department of Psychology, Arizona State University, Tempe, AZ

Saskia B J Koch, MS, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands

Madhur Kulkarni, PhD, Center for Health Care Evaluation, Veterans Administration, Menlo Park, CA

Phan Luu, PhD, Department of Psychology, University of Oregon; and Electrical ics, Inc., Eugene, OR

Geodes-Mario Mikulincer, PhD, Department of Psychology, Interdisciplinary Center Herzliya, Herzliya, Israel

Laura Nawijn, MS, Department of Psychiatry, Academic Medical Center, Amsterdam, the Netherlands

Morris A Okun, PhD, Department of Psychology, Arizona State University, Tempe, AZ

Miranda Olff, PhD, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and Arq Psychotrauma Expert Group, Die-men, the Netherlands

Jaak Panksepp, PhD, Department of Anatomy, Pharmacology and Physiology, College of Veterinary Medicine, Washington State University, Pullman, WA

Crystal L Park, PhD, Department of Psychology, University of Connecticut, Storrs, CT

Stephanie D Preston, PhD, Department of Psychology, University of Michigan, Ann Arbor, MI

Greta B Raglan, BS, Research, American College of Obstetricians and Gynecologists, ington, DC; and Department of Psychology, American University, Washington, DC

Wash-Klaus Rothermund, Department of Psychology, Friedrich Schiller University, Jena, Germany.

Jay Schulkin, PhD, Research, American College of Obstetricians and Gynecologists, ington, DC; and Neuroscience, Georgetown University, School of Medicine, Washing-ton, DC

Wash-Susanne Schwager, Department of Psychology, Friedrich Schiller University, Jena, Germany

Phillip R Shaver, PhD, Department of Psychology, University of California at Davis, Davis, CA

Ashley Shurick, BS, Department of Psychology, Stanford University, Stanford, CA

Jeanne M Slattery, PhD, Department of Psychology, Clarion University of Pennsylvania, Clarion, PA

Moria Smoski, PhD, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC

Mattie Tops, PhD, Department of Clinical Psychology, VU University of Amsterdam, Amsterdam, the Netherlands

Don M Tucker, PhD, Department of Psychology, University of Oregon; and Electrical Geodesics, Inc., Eugene, OR

Jeritt R Tucker, MS, Department of Psychology, Iowa State University, Ames, IA

Dick J Veltman, MD, PhD, Department of Psychiatry, Academic Medical Center, versity of Amsterdam, Amsterdam, the Netherlands; and Department of Psychiatry, VU University Medical Center, Amsterdam, the Netherlands

Uni-Nathaniel G Wade, PhD, Department of Psychology, Iowa State University, Ames, IA

Christian E Waugh, PhD, Department of Psychology, Wake Forest University, Winston Salem, NC

Aliza Wingo, MD, Mental Health Service, Atlanta VA Medical Center, Atlanta, GA; and Department of Psychiatry and Behavioral Sciences, Emory University School of Medi-cine, Atlanta, GA

Alex J Zautra, Department of Psychology, Arizona State University, Tempe, AZ

Mirjam van Zuiden, PhD, Department of Psychiatry, Academic Medical Center, sity of Amsterdam, Amsterdam, the Netherlands

This volume has its source in a number of activities, the most immediate one being the resilience panel presented at the 2010 meeting of the International Society for Traumatic Stress Studies, entitled “Modes of Resilience in the Treatment of Stress and Trauma: Char-acteristics and Interventions.” The development of this panel in the context of treatment approaches to posttraumatic stress brought to the fore processes involved in resilient adapta-tions to stressful challenges The study of resilience as strength-based adaptation has been a central focus of the Resilience Solutions Group at Arizona State University We appreciate the ongoing explorations with the members of this group, details of whom can be found

on the Web site: http://www.asu.edu/resilience The research activities and discussions

of this interdisciplinary group have sustained abiding vibrant interests that are reflected in the publication of a preceding handbook on adult resilience, the editing of a special journal issue, and the present volume focused on resilience approaches to stress and trauma We wish to thank the Research Department of the Phoenix VA Health Care System and the assistance of the Phoenix VA library staff members Vicki Armstrong and Mark Simmons John Reich gratefully acknowledges the love and continuing support of his wife, Deborah, and Mary Davis that of her husband, John Anderten Martha Kent thanks her husband, Dale Kent, for building a computer stand that will allow her to also work while standing at the computer, a lovely choice, as well as uncomplaining help with countless computer questions and problems

Martha Kent, Mary C Davis, and John W Reich

This volume views resilience as a process rather than as a set of traits, outcomes, and risk, or protective factors, a focus that will allow the emergence of constituent elements of resilience from the research literature Included is a review of interventions that impact adaptation

to challenge and threat in ways that result in improved functioning and well-being Future needs and directions emerge from chapter discussions throughout the volume

When considering what is really basic to resilience, the question quickly becomes a ristic in search for its elementary constituents We side with the simple definitions (e.g Szanton, Gill, & Thorpe, 2010; Zautra, 2009) that see resilience composed of three ele-ments: resilience as a sustained adaptive effort that prevails despite challenge, as a bouncing back and recovery from a challenge, and as a process of learning and growth that expands understanding, new knowledge, and new skills Szanton and colleagues refer to this three-some as resistance, recovery, and rebound and growth Resilience preserves and promotes the individuals and their contexts, as it simultaneously keeps harm at bay What are the char-acteristics that enhance and, at the same time, shield in ways that evolve into growth and a life of quality (Goodwin, 1999)?

heu-When considering resilience as a process, it is evident that resilience is markedly ied, something that involves the physical being of the person, and that it is dynamic, an action the person as a living organism does Thus, the focus of this book will be on what hap-pens with dynamic embodied persons when they express or demonstrate resilience, that is, when they prevail, bounce back, and grow from what is learned in a positive adaptive proc-ess Our emphasis will include resilience interventions that enhance resilience and achieve gains in adaptation

embod-At the top of most dictionary definitions of “process” is an understanding of the word as

a feature of nature, “a natural phenomenon marked by gradual changes that lead toward a

particular result,” such as in the process of growth (Merriam-Webster, 2011) The “process”

has a beginning, has a progression as it unfolds in multiple physical and behavioral aspects, and moves toward the result and outcome From the varied, abundant resilience literature

we will piece together parts that form a solid and comprehensive understanding of resilience

as a process

Across a wide range of writings the emergence of a consistent set of features can be grouped into three categories: intrapersonal qualities or inner processes of the person, inter-personal qualities or qualities of relationships, and social resilience or qualities of relation-ships to larger groupings Not addressed is how a resilience response is initiated and begun Discussions and studies of how resilience might get started are nearly entirely missing, while

an emphasis on the end, outcome, or result of resilience abounds, to an extent where come and protective factors most frequently define resilience This emphasis on outcome

out-and protective factors has frequently rendered opaque resilience as a coherent biological out-and behavioral process that is as coherent as the fight–flight response and as adaptive.

We propose to start with the beginnings of resilience as a process and follow its course

as it unfolds from person to context in the following steps: (1) initiation of resilience, (2) intrapersonal resilience, (3) interpersonal resilience, and (4) social resilience We also aim

to present main exemplar treatments of these groupings that: (a) show significant empirical support, and (b) are important components of positive adaptation and protect or promote well-being Resilience as outcome will not be covered, since much of the resilience literature represents this perspective well The following is a selection, partly informed by the features

of resilience found in the adult resilience literature (e.g Fry & Keysers, 2010; Kent & Davis, 2010; Reich, Zautra, & Hall, 2010), and the large developmental literature summarized in

a variety of sources (e.g Luthar, 2006; Masten, 2001; Rutter, 2006)

Resilience begins with the initiation of the first responses that occur in the face of lenge Of relevance are qualities of attentional control, particularly attention that can over-ride environmental demands, that selects, and that has direction and focus It is executive attention that is not stimulus driven and responsive to the environment but is characterized

chal-by initiative, is voluntary or emanates from the individual, and is planned (Corbetta & man, 2002) Another feature supporting initiation of a resilience response includes uncon-scious aspects such as anticipation or the preparation to respond in a ready manner, such as the action tendency of positive emotions supporting openness and approach

Shul-Resilience as process is next reviewed at the intrapersonal, interpersonal, and social levels, taking into account the modality and context of this process At the intrapersonal level the modality can be attentional flexibility (Schwager & Rothermund, Chapter 5), positive emo-tion resources (Waugh, Chapter 6), increased emotion regulation skills (Boden, Kulkarni, Shurick, Bonn-Miller, & Gross, Chapter 7), and resilience through music (Hodges, Chapter 8) Process at the interactive interpersonal level includes affiliation (Tops, Buisman-Pijlman,

& Carter, Chapter 9), social touch (Burleson & Davis, Chapter 10), empathy (Hein, ter 11), attachment (Mikulincer & Shaver, Chapter 12), and caregiving and volunteering (Brown & Okun, Chapter 13) The larger social context is treated at the adult level (Zautra, Chapter 14) and developmental level (Bradley, Davis, Kaye, & Wingo, Chapter 15)

Chap-We identify empirically tested interventions that support the above resilience processes Interventions that initiate resilience are represented by activation treatment approaches (Dichter, Smoski, Henderson, & Dimidjian, Chapter 16) and approaches that support agency (Kent & Davis, Chapter 17) Intraindividual resilience to strengthen participants’ inner resources for buffering stress include forgiveness (Wade, Tucker, & Cornish, Chapter 19) and meaning making and values (Park & Slattery, Chapter 20) Interactive interindi-vidual interventions include interpersonal skills training (Hassija & Cloitre, Chapter 21) and

an oxytocin/social contact preventative intervention (Frijling, van Zuiden, Koch, Nawijn, Veltman, & Olff, Chapter 22) Resilience interventions based on group processes and tested with larger social groupings appear to be in various phases of development or lack the empir-ical support of clinical trials and will not be reviewed The above outline is summarized in Table P.1

The chapters of this volume are organized into two sections: empirical studies of ience and the resilience interventions Within each section there are parts that treat biobe-havioral, intrapersonal, interpersonal, and social processes of resilience that cover specific expressions of these broader topics

resil-SECTION 1: RESILIENCE AS ADAPTIVE PROCESS TO STRESS

AND TRAUMA

Neurobehavioral approaches to adaptive responses to stress offer models and examine ties of attention, emotion regulation, social connections, touch, attachment, and empathy

quali-as resilient approaches

Part A: Resilience as Biobehavioral Adaptation

Jaak Panksepp examines basic flexible life-preserving behavioral and emotional patterns that form action systems supported by mammalian physiological and cortical makeup He identifies seven networks, which include SEEKING, RAGE, FEAR, sexual LUST, maternal CARE, separation-distress PANIC/GRIEF, and joyful PLAY These are survival circuits that regulate life processes and survival needs Depression results from overactivity of the separation-distress PANIC/GRIEF system and from diminished SEEKING or the dimin-ished desire to engage with the world Therapeutic approaches can promote the euphoria-enthusiasm of the SEEKING system and the positive social emotions of LUST, DARE, and PLAY

Mattie Tops, Phan Luu, Maarten A S Boksem, and Don M Tucker discuss two brain pathways for behavioral control The ventral corticolimbic pathways have specialized in

Table P.1 Summary of Resilience as an Adaptive Process and Resilience Interventions

Initiation Intrapersonal Interpersonal Social

Resilience as adaptive process:

Panksepp Schwager & Rothermund Tops, Buisman-Pijlman,

& Carter

Tops, Luu, Boksem, Waugh Burleson & Davis Bradley, Davis, Kaye,

Kent Boden, Kulkarni, Hein

Shurick, Bonn-Miller,

& Gross

Raglan & Schulkin Hodges Mikulincer & Shaver

Resilience interventions:

Dichter, Smoski, Hofelich & Preston Hassija & Cloitre clinical trials

Henderson, &

Dimidjian

Kent & Davis Wade, Tucker, & Cornish Frijling, van Zuiden, Koch,

Nawijn, Veltman, & Olff

Meaning and values

Park & Slattery

reactive behavioral control that incorporates fast associative learning that is adaptive in predictable environments This contrasts with dorsal control pathways that specialized in guiding behavior proactively by context models formed in long-term memory that are adap-tive in high-predictable environments The reactive systems produce momentary experiences close in time and space, and are emotion-focused Context model control is less immedi-ate, includes positive experience, and allows active coping Tops and colleagues discuss the involvement of these programs in the development of resilience.

low-Martha Kent samples models of approach/engagement and withdrawal/defense and of resilient flexibility to threat and challenge at biobehavioral, cognitive, and affective levels Studies of stress mechanisms have moved from concepts of homeostasis and reactive regula-tion to allostasis and long-term flexibility At the cortical level the prefrontal cortex is seen as widely interconnected and widely involved in behavioral and systemic responses to threat in circuits involving the hippocampus, amygdala, and others Recent studies consider reactive and prospective behavioral control systems

Greta B Raglan and Jay Schulkin review allostatic regulation and the physiology of change, emphasizing longer-term anticipatory and feed-forward systems in contrast to reac-tive homeostatic regulation Allostatic regulation allows coping even with severe changes and recovery from trauma Allostatic load refers to the reduction of physical and psychologi-cal ability to rebound from acute or prolonged stress The implications of allostatic regula-tion and allostatic load for resilience are discussed

Part B: Resilience as Intrapersonal Process

The inner life contributes to adaptive resilience through emotion regulation that includes automatic regulation, positive emotions, and music

Susanne Schwager and Klaus Rothermund propose counter-regulation principles in which attention is automatically oriented towards stimuli that are opposite in valence (positive or negative) to the current affective motivational focus Counter-regulation may facilitate the processing of positive (or negative) aspects of a situation Counter-regulation prevents the escalation or the emergence of chronic states and supports sensitivity to danger, thus pro-moting adaptive coping with critical life-events

Christian E Waugh starts with the robust evidence that resilient people are ized by experiences of positive emotions during stress He proposes a process model of how positive emotions might be beneficial during stress Stressors have distinct temporal phases, including anticipation, preparation, engagement, recovery, and an inter-stress period He suggests that the influence of positive emotions on stress depends on when the positive emotions occur during the stressor, such as in stress anticipation or stress recovery Future studies may benefit from adopting a process-model approach

character-Matthew Tyler Boden, Madhur Kulkarni, Ashley Shurick, Marcel O Bonn-Miller, and James J Gross describe a new model linking adaptive emotion regulation to positive out-comes, including posttraumatic growth, and maladaptive emotion regulation to negative outcomes, including posttraumatic stress Emotion regulation is conceptualized as the strat-egies people use to modify what emotions they feel, how they feel them, and how they use and express their emotions Contextual factors and emotion-specific factors influence when and how emotion regulation strategies are adaptive and maladaptive

Donald A Hodges explores music as a universal agent of resilience and coping with the circumstances of life through the examples of the role of music in enabling Jews to maintain

their traditions during 2,000 years of exile, or the singing of the anthem We Shall Overcome

by civil rights activists, or a cellist of Sarajevo performing during the Siege of Sarajevo Research evidence for the use of music for survival ranges from anthropology, through soci-ology, psychology, medicine, and biochemistry, to cutting-edge data from neuroscience.

Part C: Resilience as Interpersonal Process

Resilience is supported by interpersonal processes that regulate stress through such nisms as neuroendocrine functions of oxytocin, social touch, empathy, attachment, and caregiving

mecha-Mattie Tops, Femke T A Buisman-Pijlman, and C Sue Carter address the capacity of attachments to increase resilience in the face of stress and to resist addiction Dopamine may

be involved in the “wanting” aspect of reactive reward processing, while oxytocin as seen in attachment may be more related to “liking.” Obtaining a reward may increase the “liking” but, through satiety, decrease the “wanting” of that reward Continued drug use reduces liking and increases the wanting of drugs By contrast, strong partner relationships progress from approach or “wanting” to “liking.” Oxytocin may be involved in balancing this shift between wanting and liking, between the reactive reward systems and prospective “internal working models,” thus increasing resilience

Mary H Burleson and Mary C Davis review evidence for physical affection and other forms of touch as a major mechanism by which social contact enhances well-being They discuss the importance of friendly and nurturant touch for the formation and conduct of social relations in normal human development Social touch influences directly or indirectly psychological and physiological responding within a number of different contexts Touch indicates physical presence and may signal support or other resources for resilience

Grit Hein emphasizes the crucial role of empathy in interpersonal human emotions She reviews empirical work on empathy, from the perspective of both the empathizer and the recipient of empathy She covers recent contributions from the newly emerging field of social neuroscience She discusses the link between empathy and resilience during aversive events, such as stress and physical pain, and raises important questions for future research.Mario Mikulincer and Phillip R Shaver consider the importance of John Bowlby’s concept

of attachment for emotion regulation and mental health Research shows that attachment security acts as an inner resilience resource during periods of stress and distress Attachment security promotes reliance in the use of more constructive coping strategies, fosters positive appraisals of the world, the self, and others, and allows people to maintain emotional equanim-ity in times of stress Finally, the sense of attachment security allows people to devote mental resources to activities that facilitate psychological growth and the development of personality.Stephanie L Brown and Morris A Okun hypothesize that providing support to another

person (helping behavior) promotes the physical and psychological well-being of the helper

It improves the helper’s mood and relationship satisfaction, and reduces the negative states

of sadness Helping behavior is associated with accelerated recovery from depression and reduced mortality among caregivers Volunteering was also associated with reduced risk of mortality Why volunteering has these beneficial outcomes is analyzed An overview of the caregiver system model of active help and stress regulation is presented

Part D: Resilience as Social Process

Resilience as expressed in interactions with larger social groupings is treated in the context

of adult and developmental adaptation

Alex J Zautra identifies three components of successful resilient striving: recovery, tainability, and growth Whereas individual resilience emphasizes the personal capacities to recover and even grow stronger following stress, social resilience emphasizes how people work together to overcome adversity In social resilience recovery is a return to homeos-tasis after social loss, which is sustained through continued social engagement, and which grows through new learning This chapter illustrates how social resilience can be examined and how to intervene and enhance the capacity of people and groups to work and live well together.

sus-Bekh Bradley, Telsie A Davis, Joanna Kaye, and Aliza Wingo focus on aspects of adverse childhood experiences (ACEs) Most individuals exposed to ACEs do not develop later health, mental health, and behavioral problems This chapter focuses on empirical and theo-retical knowledge related to developmental, social, and communal factors that benefit later resilience These include proximal factors (e.g., family environment) and distal factors (e.g., neighborhood and community factors) During sensitive developmental periods the skills associated with resilience may be best nurtured

SECTION 2: RESILIENCE INTERVENTIONS

Activation and agency are illustrated by empirically tested resilience interventions that enhance strengths in response to depression, stress, and trauma These chapters are followed

by interventions that focus on intrapersonal processes and on interpersonal processes to enhance resilient functioning

Part A: Activating Interventions

Gabriel S Dichter, Moria Smoski, Roselinde K Henderson, and Sona Dimidjian review behavioral activation (BA) treatments for depression as a structured and validated reinforce-ment-based psychotherapy method that reduces avoidance behaviors and increases engage-ment with rewarding stimuli Behavior change is the primary mode of the intervention Increases in values-consistent goal-directed behaviors are theorized to increase energy, motivation, and positive thinking Recent functional magnetic resonance imaging (fMRI) data suggest that BA therapy for depression impacts striatal reward centers of the brain and prefrontal brain regions governing cognitive control of emotional processes These findings help to illuminate the pathophysiology of major depression and mechanisms for interventions

Martha Kent and Mary C Davis identify three characteristics of good survival in extreme situations: approach/engagement, social relatedness, and an efficient stress response They recognized that resilience and traumatic experiences both occurred in the same extreme environments They identified the structure of action as the important element of resilience that is prospective and goal directed rather than reactive to the immediate environment Posttraumatic stress disorder (PTSD) is seen as a disorder of action and agency, which are restored through experience-dependent simulation The re-experiencing of approach/engagement and social relatedness episodes from childhood and early adult times is applied

in a return to traumatic episodes Supporting neuroscience literature and a clinical trial are reviewed

Part B: Intrapersonal Interventions

Interventions that bolster intrapersonal processes through empathy, forgiveness, and ing making and values are reviewed

mean-Alicia J Hofelich and Stephanie D Preston report a series of studies on factors that affect success and failure in empathy They find that expressions of empathy depend on the shared experience in empathy People display their needs in different ways, and the observers’ own experiences influence observer responses Although not an intervention, their finely grained studies reviewed here can inform empathy and compassion training interventions

For Nathaniel G Wade, Jeritt R Tucker, and Marilyn A Cornish, forgiveness in the face

of interpersonal injuries is an adaptive and resilient response to stress and trauma People can be assisted in attaining forgiveness that is associated with numerous positive outcomes Forgiveness interventions increase hope and personal well-being, and reduce anger, rumina-tion, and psychological problems such as depression and anxiety

Crystal L Park and Jeanne M Slattery describe meaning-making processes in the context

of stressful events Some interventions increase general levels of meaning in life by ing a more authentic and existentially aware life Other interventions follow exposure to potentially traumatic or highly stressful events These help individuals cope with and make meaning from their encounters and help to identify areas of positive change and growth Current research and future directions are summarized

promot-Part C: Interpersonal Interventions

Strengthening interpersonal adaptation is emphasized in affective skills training and narrative story telling and by an innovative approach to stimulate the oxytocin system after trauma.Christina M Hassija and Marylene Cloitre pay particular attention to the integration of self-efficacy and emotion regulation with interpersonal effectiveness Skills Training in Affec-tive and Interpersonal Regulation (STAIR) followed by Narrative Story Telling (NST) is an example of a resilience-building treatment that promotes the acquisition and/or strength-ening of emotional and interpersonal capacities Support for the efficacy of this model as a treatment for PTSD and other co-occurring trauma sequelae are reviewed

Jessie L Frijling, Mirjam van Zuiden, Saskia B J Koch, Laura Nawijn, Dick J man, and Miranda Olff review the presence or absence of social support as modulators of stress and fear reported by many studies A familiar supportive person attenuates heart rate responses, diminishes cortisol responses to a stressor, and decreases brain activity in areas related to threat Oxytocin (OT) facilitates bonding, parental behavior, and social contact These investigators are testing the effectiveness of intranasal OT and social support in pre-venting PTSD in randomized controlled trials They review issues in an OT stimulation approach that may be helpful for oxytocin-based interventions

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1935–1943.

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Section 1

Resilience as Adaptive Process

to Stress and Trauma

Part A

Resilience as Biobehavioral Adaptation

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1 Seeking and Loss in the

Ancestral Genesis of Resilience,

Depression, and Addiction

1998, 2005; Panksepp & Biven, 2012)

Such primal affective systems ramify widely in the brain, establishing hierarchical

bottom-up controls that often dictate the more developmentally programmed top-down controls Animal research tells us more about the bottom-up controls than human research, since we have access to deep brain mechanisms Human research has much more to say about the top-down controls than animal brain–behavior relationships, since humans can provide direct ver-bal descriptors of the internal cognitive features of their minds In sum, animal research tells us much more about the cross-mammalian affective foundations of mind, while human research

is vastly more informative about higher mental abilities, many of which are truly unique to humans But the lower subcortical mind that elaborates affective consciousness (Panksepp, 2007a) is a critical platform upon which higher human mental abilities are constructed, and

is supported by the vastly expanded neocortex This nested hierarchical view is illustrated in Figure 1.1

This nested hierarchical arrangement consists of the intrinsic, foundational emotional

systems of the brain, termed primary process These systems not only generate instinctual

forms of action readiness (Darwin, 1872; Panksepp, 1982) but are also experienced as

pri-mal affective states (Panksepp, 1998, 2005) Higher cognitive elaborations, or tertiary

proc-esses, are linked to emotional feelings, the feelings that intrinsically guide not only behavioral

choices but patterns of thinking and cognitive styles that lead to top-down controls The bridge between the primary-process feelings and higher cognition is the vast intermediate

layer or secondary-process brain functions that control learning and memory Secondary

proc-ess arises from and represents deeply unconscious procproc-esses of the brain This intermediate bridge allows the affective states to interface effectively with the environment and to provide knowledge for the higher mental apparatus to generate complex perceptions, thoughts, and ideas of human cognitive consciousness This higher-order tertiary mind stuff is almost impenetrable in animal research subjects, especially since most of it is learned developmen-tally and culturally through vast plastic potentials of our expanded cortex

My focus will be largely on the foundational layer of the BrainMind,1 critical for tive consciousness It has received the least attention in neuroscientific and psychological

affec-studies of the human mind The interactions of these distinct types of tive and cognitive—can be described as state-and-channel functions of the brain (Panksepp, 2003) Their interactions are not well understood, but we can be confident that the emo-tional-affective mind is evolutionarily very ancient and homologous (genetically similar) in all mammals The cognitive layer is more recent and is capable of diverse cognitive learning about oneself and the world Determining how these levels of mind can be integrated will

consciousness—affec-be a challenge and a great opportunity for 21st-century psychology and neuroscience as well

as the topic covered here—the interrelations of mental health and resilience

The reason that affective forms are best understood neuroscientifically through brain–behavior studies of other animals, while cognitive forms are much easier to study in humans,

is simple We can directly manipulate and monitor the subcortical affective/emotional ties in animals, since those evoked states are clearly rewarding and punishing; in humans, such work cannot be conducted Animal research opens a window into human emotional primes and their mammalian neuro-evolution that can be explored empirically My guiding premise will be that adaptive strengths and weaknesses of mammalian functions will be manifested dramatically in the construction of the higher cognitive mental apparatus of humans (Solms

activi-& Panksepp, 2012), one that promotes sustainable positive affect, optimism, and resilience

as well as establishes chronic negative affect and pessimism Cognitive functions surely tribute to the emergence of affects, but their affectively desirable and troublesome features originate in the ancient psychological processes that arise from below the neocortex

con-Figure 1.1 Nested hierarchical structure of primary, secondary, and tertiary affective processes The figure

illustrates how nested hierarchies are integrating lower brain functions into higher brain functions that exert top-down regulatory control of behavior at mature development Adapted from Northoff, Wiebking, Fein- berg, & Panksepp (2011).

Twe-Way er "Circular" Causatien

Secondary-Process Learning Largely Upper Limbic

Bottom-Up Learnlng and Development

Primary-Process Emotions Affects Deeply Subcortical

Nested BrainMind Hierarchies

The social resilience of animals and humans depends heavily not only on the intrinsic (genetic) strengths and weaknesses of the primary-process emotional level, but also on how well these plastic systems have been molded by learning and the developmental/epigenetic changes that result from the world in which organisms find themselves In this chapter, I will focus mainly on one psychiatric condition, depression, while concurrently highlight-ing how early developmental joyful play experiences can modify an individual’s capacity for future affective-resilience adaptations A key position is that we can discover new thera-peutic approaches through our biological understanding of the brain substrates of specific emotions Finally, preclinical animal models can promote a foundational understanding of human positive and negative socio-affective systems that can be shifted toward more adap-tive resilient paths through epigenetic molding of the primary-process affective networks

as well as via individual learning These can promote the construction of the higher tal abilities along either enthusiastic-sanguine trajectories or negativistic-cynical ones (see a recent overview in Narvaez, Panksepp, Schore, & Gleason, 2012)

men-THE PRIMARY-PROCESS EMOTIONAL STRUCTURE OF

THE MIND

Abundant preclinical investigations with animal models in the field of affective neuroscience have now illuminated various primary-process genetically provided emotional networks of the brains of all mammals that have been studied The largest amounts of data have come from laboratory rats, which are remarkably playful, prosocial animals and, as omnivorous opportunists, have existed alongside humans throughout history All evolutionarily dedi-cated circuits for basic emotional systems are subcortically concentrated (see Panksepp & Biven, 2012 for the most recent summaries), leaving abundant room—a vast blank slate—for social constructions and elaboration in the higher reaches of the human brain, especially the neocortex (Panksepp, 2007a) Indeed, since the needed neuroscientific understanding cannot ethically be harvested from human research, animal work is critical for achieving progress in certain psychological areas of ultimate human concern: How do affective feelings arise from neural activities? Modern brain imaging can highlight many interesting correlates and higher brain regions of interest, but it can tell us little about the details of the subcorti-cal primes The lower brain is so interwoven with diverse positive and negative affective sys-tems that fMRI is often only effective in discriminating distinct affects at the nerve terminal regions of such systems, such as the nucleus accumbens for the SEEKING2 system (Knutson

& Greer, 2008) or the amygdala and associated circuits within the “limbic lobe” for FEAR (Heimer & Van Hosen, 2006; Panksepp, Fuchs, & Iacabucci, 2011)

The emotional primes are coherent unconditioned action systems of the mammalian brain At a minimum, they consist of the following seven networks: SEEKING, RAGE, FEAR, sexual LUST, maternal CARE, separation-distress PANIC/GRIEF (henceforth PANIC), and joyful PLAY The capitalization serves to distinguish primary-process affective

networks common to all mammals from vernacular terms, such as interest, anger, or anxiety,

and their particular cognitive manifestations arising from interactions with the world The emotional primes were identified with deep brain stimulation (DBS) The critical, replicable fact is that, wherever in the brain one can evoke distinct and coherent emotional responses with DBS, one can routinely demonstrate that those brain-state shifts always can be used

as “rewards” and “punishments” in simple approach/anticipation and escape/punishment learning tasks (Panksepp, 2011)

THE FUNCTIONS OF EMOTIONAL PRIMES

These affective networks are “survival circuits” that regulate life processes Affects exist because they promptly indicate whether animals are on the paths of increased or decreased survival Affects intrinsically anticipate the future, and they are major guides in the gen-esis of learning through neuropsychological “laws of affect” that have remained elusive For instance, although the mammalian brain may not have any evolutionarily dedicated

“social-attachment system,” it does have various affective-emotional circuits that rapidly mediate attachments through social-emotional learning PANIC arousal in young animals

is indexed by characteristic isolation calls as animals experience social isolation distress, a state that initially activates a vigorous general purpose SEEKING response to re-establish social reunion If that fails, animals become inactive, in a sickly way that resembles depres-sion In contrast, social reunions are experienced positively—through secure and confident positive social feelings created, in substantial part, by release of brain opioids and oxytocin (Panksepp, 1981, 1992) Such rewarding states, aroused by reunion with caretakers, are the affective “glue” that helps constitute specific social attachments and attunements As noted,

such emergent secondary-process learning results from various primary-process neuroaffective

dynamics mediated by rewarding neurochemistries such as endogenous opioids and oxytocin

(Nelson & Panksepp, 1998) If re-attachment succeeds consistently, reinforcing ence, resilience is promoted To the extent that it fails, animals succumb to chronically clingy and depressive affect, as John Bowlby (1980) well recognized in humans

independ-Because of social-ecological proximities, such rewarding states typically link youngsters

to their primary caretakers, whose nurturant CARE networks are designed to promote tained positive affective social and physical warmth, touch, and sustaining feeding activities

sus-To the extent that nurturant CARE is provided consistently, maturation is enriched by secure social attachments that form the foundation of mammalian resilience This provides youngsters with a “secure base” as they mature, promoting rich and developmentally diverse social dynamics that ultimately promote positive PLAY engagements, which help cement friendships, creating cohesively supportive social structures, and the living environmental supports for optimal resilience This is true for both humans and rats Animals that have had abundant play during early development, which can partly be fulfilled by human tickling, are more psychologically robust as they mature (Cloutier, Panksepp, & Newberry, 2012; Panksepp, 2008) To the extent that such processes do not proceed well throughout devel-opment, the incidence of mental disorders, especially depression, is increased (reviewed in Watt & Panksepp, 2009; Panksepp & Watt, 2011) This level of understanding is especially important for the goal of developing new therapies that generate positive affect and promote resilience The accrued knowledge already has important implications for understanding the fundamental social-emotional nature of both animals and humans and the role of primal emotionality in mental development and the genesis of affective disorders

DIMINISHED RESILIENCE AND THE GENESIS OF DEPRESSION

I will now expand on this neuroscientific version of the emergence of depression Sustained overactivity of the separation-distress PANIC/GRIEF system is only one-half of the equation It is one gateway to the psychic pain and increasing of depression Another major part of this equation arises from diminished SEEKING, which reflects a downward affective spiral that arises from the diminished desire to engage with the world This reflects

a weakening of the most widely expressed basic positive affective emotional network of the brain, whose substrates at the primary-process level we have called the SEEKING system Other investigators called it the “the Brain Reward System” (e.g., Haber & Knutson, 2010),

or “wanting” (Berridge, Robinson, & Aldridge, 2009), which is a good secondary-process term, or “reward prediction error” (Schultz & Dickinson, 2000), which is a reasonable cognitive-computational tertiary-process concept There is perhaps no better psychological description of this rewarding state than “desire” which promotes “euphoria” (for discus-sions see Panksepp & Moskal, 2008; Wright & Panksepp, 2012) Of course these states are created by vast orchestras of underlying neurochemistries and neurodynamics that remain barely understood

On the heels of the psychic pain and demoralization from chronic overactivity of the PANIC circuitry, the diminished arousability of the SEEKING system solidifies the emerging amotivational state that characterizes full-blown depression (Coenen, Schlaepfer, Maedler,

& Panksepp, 2011; Panksepp & Watt, 2011) Parenthetically, both over- and under-arousal

of these respective circuits can promote drug addictions, often reflecting an individual’s perate attempts to restore psychic homeostasis (for a psychobiological overview see Zellner, Watt, Solms, & Panksepp, 2011) Opioids are remarkably effective in alleviating feelings of social loss and sadness Similarly, the psychic emptiness of diminished desire (depletion of SEEKING urges) promotes the amotivational depleted psychic state of depression (Pank-sepp, 2010) The amotivational depleted state can be temporarily alleviated by psychostimu-lants, such as cocaine and amphetamines However, overuse activates BrainMind opponent-processes that further intensify feelings of psychic depletion Depressive affect is constituted

des-by the ensuing feelings of emptiness and an amotivational lack of desire (see analysis in Watt

& Panksepp, 2009) These downward spirals are solidified by the depletion of dopamine Brain dopamine and its capacity to facilitate exploration and enthusiasm are critical for keep-ing all positive emotional-motivational systems tuned

Such affective neuroscience perspectives begin to illuminate key questions and mas of biological psychiatry: why depression feels so bad and why existing antidepres-sants are only marginally effective, an observation highlighted by recent findings from STAR*D studies (Rush, 2007) From our perspective, it is because preclinical behavioral neuroscience research has not addressed one key underlying issue that can only be under-stood neuroscientifically—the deep nature of the relevant emotional affects (see Pank-sepp, 2012) Aside from our own work, neuroscientists have hardly started to study the psychic pain arising from the PANIC system, and the psychic enthusiasm arising from the SEEKING system Many still see the SEEKING system as the key mediator of sensory pleasure or only cognitive-computational parts of a whole organism These higher parts are represented by the “wanting” and “reward prediction error” perspectives In order to

dilem-understand psychiatric disorders as well as the nature of resilience, it is the primal affects

that need central consideration, because they are directly tied to the organism’s survival These are not just sensory parts, such as taste and touch, or homeostatic ones of thirst and hunger The reason for inattention in biological psychiatry to the foundational primary nature of the SEEKING system is perplexing It may be an entrenched remnant of “never-mind” behavioristic biases in animal brain research

In our estimation, more effective non-addictive medicines and neurobehavioral approaches can be found that promote the euphoria-enthusiasm power of the SEEKING system and can concurrently promote the three positive social emotions of LUST, CARE, and PLAY

It is among their shared (dopamine) and unique (various neuropeptide) positive affective neurochemicals that effective neurobehavioral and medical antidepressants may be found

Indeed, by using such affective neuroscience strategies, new neurobiological ing approaches and medicines can be identified The beneficial exercise of the SEEKING systems may be achieved through a number of neurobehavioral approaches, such as regular physical exercise or therapies that focus on behavioral activation (Dichter, Smoski, Hender-son, & Dimidjian, Chapter 16, this volume), agency building (Kent & Davis, Chapter 17, this volume), psychological coherence (Toomey & Ecker, 2007), and others The first such targeted medication, GLYX-13 (see Burgdorf, Panksepp, & Moskal, 2011), recently passed Phase 2 FDA approved human testing The resilience topics explored in this volume open the way to synergistic psychological strength-building approaches.

resilience-build-ON THE SHORTCOMINGS OF PAST PRECLINICAL AND

MEDICINAL APPROACHES TO DEPRESSION

As a result of the behaviorist bias of the Anglo-American animal research tradition, cal depression research during the last four decades of the 20th century focused most heavily

preclini-on the cpreclini-onsequences of global stress (McEwen, 2007) and brain norepinephrine and tonin dynamics (see Panksepp, 2004)—namely on those widely ramifying neurochemical pathways that modulate practically everything that animals do It was, and still is, deemed scientifically inappropriate to consider the nature of emotional feelings in animals, because their minds are deemed to be either non-existent or scientifically impenetrable Accordingly, various key psychiatrically relevant questions, such as the nature of affect, have remained widely neglected The consequence is that few new psychiatric medicines have been devel-oped in the past half-century of brain research (Panksepp, 2012) Few investigators in ani-mal research have asked why depression feels so horrible In contrast, our provisional answer

sero-is that the most common instigating negative feelings arsero-ise from excessive and sustained arousal of PANIC networks that set in motion cascades of brain changes whereby the life-affirming euphoric potentials of SEEKING are depleted (Coenen et al., 2011)

In contrast to general behavioristic and pure molecular neuroscience approaches, tive neuroscience strategies seek preclinical models that directly stimulate the relevant nega-tive affective systems of the brain, such as the midbrain’s dorsal periaqueductal gray, while monitoring changes in affect with measures that describe capacities to sustain positive social affect (Wright & Panksepp, 2011) In rats, diminished positive affect is monitored by an objective “psychoassay”—sustained reductions in a validated indicator of enthusiastic inter-nal states, namely the 50 kHz ultrasonic vocalizations (USVs) that arise from the brain SEEKING/PLAY circuits Those playful, joyous sounds of social eagerness are well-vali-dated indicators of euphoric positive affect (Burgdorf, Wood, Kroes, Moskal, & Panksepp, 2007) Under natural conditions, these positive affective vocalizations are never more highly expressed than during the rough-and-tumble play of juvenile rats (Panksepp, 2007b) that can be simulated and even further amplified by human tickling

affec-The natural social play of juvenile rats, as well as systematically evoked playfulness and joy, can be achieved by human tickling of rats This approach has yielded procedures for the discovery of antidepressive, resilience-promoting neurochemical pathways in the brain.Our search for new joy-pathways was initiated by microarray monitored brain gene expression changes in adolescent animals that had just experienced abundant social PLAY Such play arouses the mesolimbic dopamine energized SEEKING circuitry that is conflu-ent with the transhypothalamic medial forebrain bundle (MFB; for a modern anatomical description of this important positive motivational system in humans see Coenen, Panksepp,

Hurwitz, Urbach, & Mädler, 2012) By studying the gene expression effects of social play

on the brain, we identified a variety of candidate biochemical systems as antidotes for sion (for related work using a social defeat model see Burgdorf et al., 2011, and Krishnan & Nestler, 2008) We also identified clues for the treatment of other disorders such as autism (Moskal, Burgdorf, Kroes, Brudzynski, & Panksepp, 2011)

depres-Our strategy in searching for an antidote for depression was to look among the ous neurochemical candidates for pathways that directly promote positive social affect and neuropsychological potentials for resilience through the “power of PLAY.” There are good reasons to believe that the long-term recruitment of such mental energies could help coun-teract various recalcitrant childhood problems (such as childhood impulsivity) through the capacity of such prosocial activities to promote both socialization and brain maturation (Panksepp, 2007b) We conducted various lines of research to evaluate the credibility of our juvenile play model as an entry point into understanding positive social affect Indeed, we found that play evoked widespread neuronal activation changes within the brain (Gordon, Kollack-Walker, Akil, & Panksepp, 2002), suggesting interesting clinical possibilities Play could also beneficially “fertilize” the brain by promoting other depression-related growth factor pathways, such as Brain Derived Neurotrophic Factor (BDNF; Gordon, Burke, Akil, Watson, & Panksepp, 2003; Gordon et al, 2003) and Insulin-Like Growth Factor 1 (Burg-dorf, Kroes, Beinfeld, Panksepp, & Moskal, 2010), which are diminished in depression For instance, BDNF promotes antidepressant genetic cascades in the brain that oppose the hip-pocampal damage that often accompanies depression (McEwen, 2007)

vari-In this context, it is noteworthy that our preclinical resilience-promotion through tive affect consisted of the systematic tickling of rats that resulted in hedonic 50 kHz USVs under strict experimental control This approach has promoted antidepressant-like effects

posi-in animal models, such as hippocampal neuronal growth (Wöhr et al., 2009), as well as increased animal well-being (Cloutier et al., 2012) To re-emphasize a key point, since these

50 kHz USVs have been mapped onto the mesolimbic dopamine “energized” SEEKING system (Burgdorf et al., 2007), investigators can now readily monitor state shifts in euphoric eagerness that have the potential to counteract depressive affect Furthermore, along with the negative 22 kHz USVs, those positive USVs can be formally used to index experienced social affective shifts in rats, which can illuminate the underlying affective changes that char-acterize depression (Kroes, Burgdorf, Otto, Panksepp, & Moskal, 2007)

TREATING SYMPTOMS VERSUS RESTORING STRENGTHS: THE CASE OF DEEP BRAIN STIMULATION (DBS)

ANTIDEPRESSANT THERAPIES

As interventionists, we have a choice of treating the pain or evoking strengths Affective science concepts are providing a platform for the advanced use of DBS as novel interventions for treatment resistant depressions (Bewernick et al., 2010; Mayberg, 2009; Schlaepfer et al., 2008) Indeed, the separation-distress PANIC system may be one gateway to depression in its ability to maintain much of the psychic pain so characteristic of depression The PANIC cir-cuitry originates in the midbrain periaqueductal gray (PAG), ascends through the dorsomedial thalamus, and terminates in anterior cingulate forebrain regions DBS-induced disruption of this system may account for treatment effectiveness by inhibiting the upper anterior cingulate areas of the PANIC system that helps generate and sustain the psychic pain of depression.DBS can also be applied to promote relevant psychological strengths Thus, an equally

neuro-important advance in DBS antidepressant therapy may be to facilitate arousal of the ING system in order to restore the desire of depressed people to be active agents in the world To the best of our knowledge, the SEEKING system is critically important for generating eager “intentions-in-action”—the enthusiastic, spontaneous engagement with affordances in the environment—that are so deficient in depression This system seems to

SEEK-be the foundation of personal “agency.” Indeed, several studies have already found solid antidepressant effects from DBS applied to key terminal regions of the SEEKING system

in the ventral striatum (e.g., nucleus accumbens), where the initial evidence of a treatment response is the tendency of individuals to begin planning pleasant activities for the future (Schlaepfer et al., 2008)

Considering that SEEKING arises from the trans-hypothalamic medial forebrain bundle (MFB), we have suggested that DBS applied to this pathway should promote significant antidepressive effects (Coenen et al., 2011, 2012) Indeed, results from a preliminary clini-cal trial on seven treatment resistant depressive patients by colleagues have already yielded positive results in six of seven patients treated with DBS (V A Coenen & T E Schlaepfer, personal communication) This work is beginning to fulfill our goal to interface our grow-ing understanding of these affective systems with human emotional functioning in order to achieve a better understanding of psychiatric disorders (Panksepp, 2004, 2006)

IN SUMMATION: AFFECTIVE NEUROSCIENCE APPROACHES TO EMOTIONAL MINDS AND RESILIENCE

The affective neuroscience approach to understanding the emotional mind of all mammals (Panksepp, 1982, 1998, 2005) makes two key assumptions that allow us to address impor-tant and difficult questions in basic psychological research and clinical practice in ways that are novel and productive First, primal emotions and their associated feelings have evolved

to do something specific in relation to biologically significant life-challenging situations They are not mere epiphenomena, as is commonly assumed in behavioral neuroscience Second, the experience aspects of primary-process emotions—specific kinds of affects that have been built into the brain and shared homologously by all mammals—serve three key adaptive “purposes”: (a) They highlight key survival and reproductive demands in the ambi-ent environment, with positive affects indexing situations that increase and negative affects that decrease an animal’s chances of surviving to reproduce (b) They motivate organisms

to behave in ways that promote survival and reproduction by providing a ral compass that leads to individual safety and reproductive success (c) They promote the construction of memory through neural systems that strengthen learned behaviors by yet unfathomed “laws of affect.” These laws should replace the behaviorist “law of effect” based

psychobehavio-on “rewards” and “punishments” that modify the frequencies of particular behaviors, a law that never considered the inner psychological lives of humans or other animals Experienced

affects are survival-enhancing, adaptive codes to anticipate biological survival demands, just

as hunger anticipates our long-term need for energy rather than a drastic reduction of ing supplies Affects are not psychological epiphenomena, but the emissaries of critical brain adaptations that promote life

exist-Accordingly, we advance an emotional-affective view of all mammalian species The son the behaviorist and affective neuroscience approaches can finally be brought together is simply because, everywhere in the brain that one can evoke coherent instinctual emotional behaviors using DBS, one can demonstrate that the evoked internal states are rewarding or

rea-punishing It is critical to appreciate the fact that experienced affects are functional Positive affects automatically signal to animals that they are on paths likely to increase their fitness Negative affects inform them that they are in life-diminishing/threatening situations and provide neural “reinforcement” for unconditional escape and learned avoidance strategies Thus, among these emotional primes, four mediate affectively positive behavioral urges: namely SEEKING, LUST, CARE, and PLAY, with the last three heavily utilizing the SEEK-ING urge And three mediate affectively negative emotions: RAGE, FEAR, and PANIC There are other primal affects, such as the many sensory and homeostatic ones that are of less relevance for understanding resilience and the lack thereof Because the primal emotion systems are probably important for the genesis of depression and other psychiatric disorders,

we have developed a scale to evaluate the strengths and weaknesses of the primal emotions

in humans (Davis & Panksepp, 2011) This measure may be of substantial value to chologists and psychotherapists by providing a common metric to estimate the status of the primal emotions in the lives of their subjects and clients A composite of high scores on the three positive subscales (SEEK, CARE, and PLAY) may index general “positive affect” and resilience A composite high measure of the three negative subscales (ANGER, FEAR, and LONELINESS) may index lack of resilience The ratio of the two may combine the positive and negative affective tendencies into a supraordinate factor that could serve as an overall measure of psychological health and capacity to face the world with resilience

psy-CONCLUSIONS

An understanding of the neural infrastructure of emotional processes can promote our understanding of resilience and inform the crafting of new therapeutic approaches This knowledge can help clinicians to consider new psychotherapeutic approaches, including bet-ter utilization of positive affects that arise from the SEEKING and PLAY systems I have briefly summarized how we can harness the SEEKING system to build up positive social affects that diminish the psyche-destructive forces of sustained PANIC and the overwhelm-ing feelings of the psychic pain of separation distress This will establish desirable Brain-Mind states for the promotion of resilient states In this short review, I have drawn only marginal attention to the vast terrain of “granular” neuroscientific detail that underlies the surface layer of psychological functions and that need to be sifted through before we really understand the foundations of such global concepts as resilience But clinicians need to understand that the level of relevant anatomical, neurochemical, and neurogenetic detail can already fill several volumes

My goal here was simply to provide an overview of the affective neuroscience research program we have undertaken in order to point to and clarify the underlying brain emotional systems and their neurobiologies that support human thriving This emphasis is particularly important to the downhill cascade of negative affects that can promote clinical depression

We can finally understand the neural nature of the various basic emotional affects of malian brains

mam-We anticipate that these global brain states represent a critical law of nature that can minate psychiatric and psychotherapeutic practice: Those biobehavioral and neuroendocrine functions that promote positive affects will facilitate long-term psychological learning and resilience Those biobehavioral functions that promote negative affects will hinder resilience Most of the time organisms negotiate both in adaptive life-enhancing ways Although there are many evolutionary levels to the brain and mind, most not yet very well understood at

illu-either neuroscientific or psychological levels, we do know the following with some ance: Those systems that promote negative affects are destructive to mental health In con-trast, maneuvers that can promote positive affective coherence and integration will enhance mental health These factors hold for humans as well as other creatures with whom we still need to learn how to share the earth When we finally understand the affective nature of their minds, we will begin to have a firm science of our own That knowledge will transform our search for new mind medicines and improve the effectiveness of our psychotherapies.

assur-NOTES

1 The expression “BrainMind” represents Panksepp’s solution to the mind-body dualism, as discussed

at some length in Appendix C (Panksepp, 1998, p 336) BrainMind refers to the dual-aspect monistic ontology in which brain and mind are “two sides of the same coin.” In BrainMind emotional affects are part of the instinctual emotional action systems of the brain that are homologous across all mammals The BrainMind represents “nested hierarchies” of control, as represented in Figure 1.1 BrainMind is used interchangeably with MindBrain (see Panksepp & Watt 2011).

2 The upper case terms of SEEKING, RAGE, FEAR, PANIC, LUST, CARE, and PLAY are affective designations that refer to genetically endowed brain emotional operating systems They are in upper case in order to alert the reader that these designations represent scientifi c rather than vernacular usage; specifi cally they represent neural systems of the brain (see Panksepp, 1998, p 51).

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2 The Roles of Predictive and

Reactive Biobehavioral Programs

in Resilience

Mattie Tops, Phan Luu, Maarten A S Boksem,

and Don M Tucker

In this chapter we propose a theory in which behavior (broadly comprising relevant tion, emotion, and behavior) and physiology are coordinated and integrated by a number of

cogni-separate behavioral and physiological programs, for convenience termed here biobehavioral

programs We propose that resilience may vary over time and between persons, depending

on which program exercises control over behavior More specifically, we will describe two main biobehavioral programs that control behavior adaptively in low-predictable and in highly predictable environments respectively Behavior and emotions guided by the first program are highly reactive, while behavior and emotions controlled by the second program are guided by models of behaviors that are optimal in their own contexts and that have been consolidated in memory to form context models Here, we will argue that interventions and

experiences that increase resilience may accomplish this by shifting control from the reactive program to the context model program.

Ventral corticolimbic control pathways in the brain are crucially involved in reactive behavioral control that includes fast associative learning, seen as highly adaptive in unpre-dictable environments By contrast, dorsal corticolimbic control pathways are specialized for slow stable learning that is adaptive in highly predictable environments Dorsal control pathways guide behavior in a feed-forward fashion by using models of the context that are stored in long-term memory The reactive system produces a momentary, immediate sense

of awareness in which emotional events and stimuli are experienced as close in time and space Because of this immediacy of emotional experience, reactive control is associated with emotion-focused coping By contrast, in episodes where context models guide and control behavior, emotional experience is less immediate and overwhelming In addition, context models that are successfully used in predictive control will tend to include representations of positive experiences and outcomes This positive bias and these less intense emotions enable active coping through confronting both negative and positive affective events and stimuli

We will discuss how these programs are involved in the development of resilience

We propose that, during evolution, biobehavioral programs developed to orchestrate different aspects of behavioral and physiological control systems; each program adapted to

a particular set of contexts and conditions (Tops, Boksem, Luu, & Tucker, 2010) Aspects

of the control systems include arousal, information processing biases, action control, cific cognitive operations, and, importantly, specific motivation We draw on Panksepp’s (1998) levels of affective mind-brain organization to illustrate the depth and breadth of

spe-these biobehavioral programs, which we see as integrating primary process emotions that arise from evolutionarily provided subcortical operating systems, secondary process emotions that

reflect basic emotional learning and memory processes as reflected in classical and operant

conditioning, and tertiary process emotions or the higher emotional functions of thought and

deliberation included in episodic/autobiographical memories, symbolic thought, and munication (Panksepp, 1998; Panksepp, Chapter 1, this volume) Our discussion does not focus on differences between primary, secondary, and tertiary process aspects of emotions but on ventral and dorsal corticolimbic system programs in which each combines specific elements at all three process levels.

com-Finally, we propose that resilience can be increased in reactive individuals (i.e., persons

in whom the reactive control program tends to dominate) by increasing capacities to shift toward context model biobehavioral programs The brain appears equipped with mecha-nisms to make this shift, and individuals often display such a shift during skill acquisition and performance learning Resilience may be increased through the application of similar learn-ing mechanisms to the control of behaviors and emotions in negative environments

In the following sections, we first describe the two types of control systems, reactive and context model programs Then we discuss mechanisms for shifting between these two con-trol systems and discuss how they bolster resilience Finally, we review evidence for how this shift may be applied to strengthen resilience through certain interventions, experiences, and behaviors such as emotion regulation, impulse control or “cool” vs “hot” control, mind-fulness meditation, and certain psychopharmacological agents We discuss the evidence for how this shift may be involved in strengthening resilience through the cultivation of posi-tive emotions We also consider the relation of our model to other theories that explain the effects of emotions on cognition and resilience

THE VENTRAL AND DORSAL CORTICOLIMBIC CONTROL

PATHWAYS OF THE REACTIVE AND CONTEXT MODEL

BIOBEHAVIORAL PROGRAMS

We have argued for an evolutionary process underpinning the development of partially separate ventrolateral and mediodorsal control pathways that supported two behavioral pro-grams adapted to different environments (Tops & Boksem, 2011a, 2012; Tops et al., 2010),

as illustrated in Figure 2.1

The first program, termed the reactive program, incorporates the ventral corticolimbic control pathways, including inferior frontal gyrus (IFG), anterior insula (AI), amygdala, and anterior medial temporal lobe The reactive program promotes fast associative learning that is adaptive in low-predictable environments The reactive program contrasts with the second program, termed the context model program, which incorporates the dorsal control pathways that include posterior cingulate cortex, precuneus, posterior medial temporal lobe, and dorsolateral prefrontal cortex The dorsal control pathways are specialized for guiding behavior with context models that are formed and kept stable by slow learning, a specializa-tion that is adaptive in predictable environments Context models are formed in long-term memory by the predictability of the environment/context

In low-predictable environments, effective context models generally cannot be formed quickly nor used to control behavior quickly in adaptive ways Instead, behavior is guided reactively by momentary feedback from environmental stimuli through ventral corticolim-bic control This reactive guidance by momentary environmental stimuli is associated with attention focused on stimuli that are urgent and close in time and space Those stimuli can

be positive (“I have to catch that reward that is in my reach before it gets away”) or tive (“I have to get away from that danger before it gets me, because I’m in its reach”) By contrast, there is less urgency and focus on the moment (i.e., less narrow, more global focus

nega-in time and space) when behavior is guided by context models nega-in feed-forward fashion (“I will plant these seeds now, so that I have food for the coming winter, just like last year,” or

“I will repair the fence around my chicken pen, so that foxes will not steal the eggs”) Table 2.1 summarizes the ventrolateral and dorsomedial control models

Classical work has shown that states of affective arousal carry resource information logical resources such as glucose levels and the condition of muscles, as well as social resources) and that these states are associated with implicit perceptions of coping abilities (Thayer, 1989) Only in low-predictable environments is it necessary to have a continuous readout of the level of available resources to inform immediate action In the ventral corticolimbic control pathway, via the IFG and AI, information about the level of resources is combined with emo-tional or “drive” information that biases the direction of action either towards (i.e., approach behaviors like craving, hunger, love, trust) or away from (i.e., avoidance behaviors like disgust, pain, distrust) a target object (Tops & de Jong, 2006; Tops et al., 2010) This directional drive property may have developed from functions of the gustatory cortex that is situated in the insula The directional drive bias and information about resources are further combined with relevant target information and, depending on circumstances, with priming or prepara-tion for action responses and with matching autonomic responses Together, the continuous readout of the direction of drive, resource levels, and orientation to potential targets enables fast, opportunistic action on the spur of the moment

(physio-Figure 2.1 Left: Primary direction of corticolimbic traffic for organizing output from limbic integration

toward specific action modules in the motor cortex Two separate control paths are routed from limbic networks through the frontal lobe to the motor cortex A ventrolateral pathway proceeds from the olfactory cortex through the orbital frontal lobe to the lateral frontal cortex before reaching the ventral premotor and motor cortices (ventral/bottom arrows) A mediodorsal pathway proceeds from the cingulate gyrus through the medial frontal cortex to the dorsolateral frontal cortex to the premotor and motor areas on the lateral

convexity of the hemisphere (upper/dorsal arrows) Right: Primary direction of corticolimbic traffic for

inte-grating perception from specific modules in the sensory cortex (in this case the arrows start from the visual area) toward the limbic cortex shown for dorsal (upper arrows) and ventral (bottom arrows) From Tucker (2007), copyright.

ventral Visual Pathway

The posterior cingulate cortex and precuneus, which are connected to the dorsal striatum and dorsolateral prefrontal cortex, are considered the dorsal endpoint of the rostral-ventral to caudal-dorsal gradient within the cortex, and as mediators of the dorsal control pathway This may seem at odds with findings that identify these areas as important for self-reflection and as central to the “default mode network” that is active at rest and deactivates during many cogni-tive tasks However, it is important to realize that self-reflection may be possible only at rest, and when performing habitual actions (in which the dorsal striatum is important), since atten-tion in both cases is not involved with other processes Self-reflection may involve activation

of memories of the self in contexts (context models) Although retrieval and action control may partly dissociate during self-reflection, true context model-guided control is informed by previous experiences with specific contexts and involves engaging in increasingly automated

or habitual behaviors The default mode network has been proposed to support the ability to perform internal mentation by providing a platform for assembling dynamic internal mental models and scenarios (Buckner & Carroll, 2007) Typically, these scenarios would contain ele-ments of autobiographical episodic memory and self-related prospective thoughts It has also been suggested that the purpose of continuous internal mentation may be to act as a simulator and predictor of future events that are built from previous experiences (i.e., context models)

In many situations and for many tasks, dorsal and ventral systems will collaborate and interact in the control of behavior For example, findings support the interactions between IFG and dorsal frontal areas When IFG implements reactive (momentary) immediate action according to the information from contextual signals, dorsal frontal cortical areas simul-taneously implement “predictive” episodic motivation control and sustain control over behavioral episodes The dorsal control is achieved through information conveyed from

Table 2.1 Comparison of Ventral and Dorsal Control Pathways: Summary Features of Ventral Corticolimbic

Control and Dorsal Corticolimbic Control

Ventral corticolimbic control pathway Dorsal corticolimbic control pathway

Environment:

Behavior:

Direct sensitivity to + and – environmental Less direct responsivity to environmental

Reactive guidance—by momentary feedback Predictive context model guidance formed in

Attention focus is on urgent stimuli, narrow Less urgent, less narrow

Fast associative learning: fast opportunistic Slow learning previous experience with specific

simulate and predict future events that build on previous experience (context models)

Ventral control bias = distressed in most Dorsal control bias = not distressed in most

Brain functions:

Amygdala Precuneus

temporally remote events (or context models), from the history of actions and outcomes, and from implementation of feed-forward control of behavioral patterns and their integrated action sequences However, temporary as well as relatively stable biases for reactive control may result from temperament, unpredictable dangerous or urgent situations, perceptions

of unpredictability after trauma or inconsistent parenting, and interactions between these factors By contrast, a bias for context model-guided control may stem from a different temperament, and may follow consistent parenting and a predictable, secure early environ-ment that favors exploration and the development of context models (i.e., internal working models of Bowlby’s attachment theory, 1988)

DORSAL AND VENTRAL MECHANISMS OF RESILIENCE

The reactive and context model behavioral programs associated with ventral and dorsal control systems, respectively, have evolved because they are adaptive in certain environments and circumstances Both the dorsal and the ventral programs are associated with talents and sources of resilience However, while the reactive ventral programs are directly sensitive and responsive to both negative and positive environmental influences (including the social environment), the dorsal programs make use of context models and are, thus, less responsive

to environmental influences Because of this different responsivity of these biobehavioral programs, individuals who are biased towards dorsal control will generally not be distressed

in most environments and adapt well On the other hand, individuals who are biased toward ventral control may experience distress in many different environments Such individuals may benefit from an increased capability to shift to dorsal control We will focus on increas-ing resilience through shifting from ventral to dorsal control (i.e., from reactive to context model), because we believe this process is involved in various interventions or mechanisms that bolster resilience We will discuss several examples in the following sections

We propose that resilience can be increased in reactive individuals by increasing capacities to shift to context model biobehavioral control programs The brain is actually equipped to make this shift, a shift that is often evident during the learning of skills Resilience may be increased

by similar learning mechanisms that are applied to behavioral and emotional control in tive environments Human and animal studies identify three elementary learning systems in the stages of skill acquisition One system represents rapid and focused acquisition of new skills during threats and violations of expectations The second system is a gradual process of updat-ing a configural model of the environmental context These two learning systems correspond

nega-to the ventral and dorsal corticolimbic control pathways discussed above During learning, the ventral system is strongly involved in the early phase of learning, while the dorsal control system comes online later as learning progresses (Luu, Shane, Pratt, & Tucker, 2009).The engagement of each system during the course of learning is dependent on the nature

of the events within the learning task Certain tasks may express a third system, the formation system in the dorsal striatum Recent behavioral studies in both humans and rodents have found evidence that performance in decision-making tasks depends on two different learning processes: one encodes the relationship between actions and their conse-quences and the second involves the formation of stimulus–response associations (Balleine

habit-& O’Doherty, 2010; Luu, Shane, Pratt, habit-& Tucker, 2009) These two learning processes are thought to govern goal-directed and habitual actions, respectively It appears likely that cooperation or competition between these sources of action control depends on the third learning system, which incorporates the cortico-basal ganglia network within which the