Coping With Moving to Another Coutry Peer Reviewed Sources
Psychiatry (Edgmont). 2007 May; iv(five): 35–twoscore.
Published online 2007 May.
Social Support and Resilience to Stress
From Neurobiology to Clinical Practice
Fatih Ozbay, Physician, 
Douglas C. Johnson, PhD, Eleni Dimoulas, PhD, C.A. Morgan, III, Doctor, MA, Dennis Charney, Doctor, and Steven Southwick, Dr.
Steven Southwick
Drs. Ozbay, Johnson, Dimoulas, Morgan, and Southwick are from Yale University School of Medicine, New Haven, Connecticut, and the National Center for PTSD, Clinical Neurosciences Partitioning, VA Medical Center, West Haven, Connecticut; and Dr. Charney is from the Mountain Sinai Schoolhouse of Medicine, New York, New York.
Abstract
Numerous studies bespeak social support is essential for maintaining physical and psychological health. The harmful consequences of poor social support and the protective effects of adept social back up in mental illness accept been well documented. Social support may moderate genetic and ecology vulnerabilities and confer resilience to stress, possibly via its furnishings on the hypothalamic-pituitary-adrenocortical (HPA) system, the noradrenergic system, and central oxytocin pathways. There is a substantial need for additional research and development of specific interventions aiming to increase social support for psychiatrically ill and at-risk populations.
Keywords: social back up, health, resilience, stress, cortisol, oxytocin
Introduction
Social back up is exceptionally important for maintaining good concrete and mental health. Overall, it appears that positive social support of high quality tin raise resilience to stress, help protect against developing trauma-related psychopathology, decrease the functional consequences of trauma-induced disorders, such as posttraumatic stress disorder (PTSD), and reduce medical morbidity and mortality.ane However, despite strong show demonstrating the beneficial effects of social support on medical and psychological wellbeing, the field of psychiatry has contributed relatively little to developing, testing, and implementing effective evidence-based interventions aimed at increasing social support for patients and at-risk populations. In this review commodity, we aim to summarize key studies on social support in the context of resilience to stress and explore possible encephalon mechanisms mediating social support'south positive influence on mental health outcomes. Nosotros will begin with a cursory overview of the neurochemistry of the stress response and resilience to stress. Within this framework, we will then review the emerging literature on the neurobiology and the behavioral mediators of social back up. Adjacent, we will review studies that have investigated the furnishings of social support on medical illness, and finally, conclude with a discussion on social back up'southward clinical significance for psychiatry.
Resilience to Stress: Putative Mechanisms
Psychological resilience represents a procedure of adapting well in the face of adversity. The psychosocial and neurobiologic characteristics of resilience to stress are extremely complex, and their discussion is across the scope of this article (for a thorough review see Southwick, et al.i). All the same, the literature suggests the sympathetic nervous arrangement and hypothalamic-pituitary-adrenocortical (HPA) arrangement are extensively involved in stress response and resilience.2
The sympathetic nervous system (SNS) responds to stress past increasing heart rate, constricting blood vessels, increasing blood pressure, and slowing digestion. Numerous lines of evidence from psychophysiology and neuroendocrine studies indicate that the noradrenergic organization is often dysregulated in PTSD. For example, chronic PTSD is associated with high baseline cerebrospinal fluid NE concentrations.three McFall, et al., demonstrated that subjects with gainsay-related PTSD had greater increases in plasma epinephrine, pulse, and blood pressure in response to viewing a combat flick.4 Notably, the heightened autonomic activity of PTSD patients peaked during the resting period after the combat film, and the authors argued that an damage of the mechanisms involved in terminating the noradrenergic response to stressors was implicated in the pathophysiology of PTSD. When the SNS is strongly activated, neuropeptide Y (NPY) and galanin are released with norepinephrine to maintain SNS activity within an optimal activation range (reviewed by Southwick, et al.5). Indeed, highly resilient special operations soldiers tend to have high levels of NPY6,7 in contrast to gainsay veterans diagnosed with PTSD who accept reduced levels.8 The overall net furnishings of NE hyperactivity thus may depend on the remainder between NE, NPY, and galanin. This supports the notion that resilience to stress is associated with the regulation of noradrenergic activity within an optimal window.
In response to acute and chronic stress, the hypothalamus secretes corticotropin-releasing gene (CRF), which in plow induces the release of adrenocorticotropin hormone (ACTH). ACTH stimulates the synthesis and release of cortisol and dehydroepiandrosterone (DHEA) from the adrenal gland. In the short run, cortisol mobilizes and replenishes energy stores and contributes to increased arousal.nine However, if stress remains chronic, prolonged elevations of glucococorticoids may cause serious adverse effects, such as immunosuppression, hypertension, dyslipidemia, and osteoporesis.ten In contrast to cortisol, DHEA exerts antiglucocorticoid and antiglutamatergic activity in the encephalon and may confer neuroprotection (reviewed past Charney2). For example, a negative correlation has been demonstrated between DHEA levels and PTSD symptom severity in women.xi Morgan, et al., constitute a positive correlation between DHEA/cortisol ratio and performance among special forces soldiers during high stress training.12 Similarly, allopregnalolone, another neuroactive steroid, dampens the HPA activeness. Rasmusson, et al., has reported lower cerebrospinal fluid levels of allopregnanolone in those diagnosed with PTSD compared to controls.13 In conclusion, DHEA and allopregnalolone may confer resilience to stress by helping to terminate HPA-activation and preventing harmful effects of prolonged exposure to glucocorticoids.
In summary, stress resilience seems to be associated with an power to keep the HPA-axis and noradrenergic activity within an optimal range during stress exposure and terminate the stress response in one case the stressor is no longer present. Based on these findings, nosotros may postulate that for social support to increase stress resilience, information technology should enhance the power to optimize the neurochemical stress response summarized higher up.
What is Social Back up?
Social back up has been described equally "back up accessible to an individual through social ties to other individuals, groups, and the larger community."xiv The National Cancer Institute'south Lexicon of Cancer Terms defines social support as "a network of family, friends, neighbors, and community members that is available in times of demand to give psychological, physical, and financial help" (www.cancer.gov). Theoretical models of social support specify the following two of import dimensions: (1) a structural dimension, which includes network size and frequency of social interactions, and (2) a functional dimension with emotional (such every bit receiving love and empathy) and instrumental (practical help such equally gifts of money or assistance with child intendance) components.2 Nearly enquiry has found that quality of relationships (functional dimension) is a better predictor of expert health than quantity of relationships (structural dimension), although both are of import.1
It should be noted that the optimal source of social support may depend on the developmental stage of the person who is receiving the back up. For example, parental support seems to be more than valuable in early adolescence than it is in late adolescence.15 It has been shown that the perception of social back up is associated with the degree of social interaction in the elderly and with instrumental support in younger adults.16 Moreover, the type of social support seems to be important in conferring resilience to stress. In a sample of babyhood sexual abuse survivors, a combination of self-esteem back up (the private perceives that he or she is valued past others) and appraisal support (the private perceives that he or she is capable of getting advice when coping with difficulties) was most useful in preventing the development of PTSD.17
The Psychobiological Mediators of Social Support
Investigators have explored the ways in which social support may enhance mental and physical wellness. Information technology has been argued that rich social networks may reduce the rate at which individuals engage in risky behaviors,18 forestall negative appraisals,nineteen and increment handling adherence. In full general, resilient or hardy individuals are thought to use active coping mechanisms when dealing with stressful life situations.20 Using a time lag model for the prediction of depression, Holohan, et al.,21 found that high social support predicted less subsequent depression in patients with acute and chronic cardiac illness and that this relationship was partly mediated by the use of an active coping fashion. Chiefly, in this cohort, social support preceded and facilitated the use of active coping mechanisms.
There is an emerging literature on social support and the neurobiological pathways through which it acts to foster resilience and reduce the hazard for developing mental illness. In preclinical studies, social isolation has been associated with increased eye rate and claret pressure, hypercortisolemia, and atherosclerosis. For example, amongst cynomolgus monkeys, resting heart rate increases during separation and isolation but returns to normal when monkeys are reunited with their social group;21 cortisol rises in squirrel monkeys22 and wild baboons23 during isolation; at postmortem exam, atherosclerosis has been significantly greater in swine24 and in female monkeys21 living alone vs those living in social groups. Further, prove suggests chronic stress and lack of social support increases cardiac risk (e.g., endothelial injury, increases platelet accumulation), in part, through prolonged sympathetic activation.25
In homo studies, depression social support has been associated with physiological and neuroendocrine indices of heightened stress reactivity, including elevated heart rate,26 increased claret pressure,27 and exaggerated cardiovascular and neuroendocrine responses to laboratory stressors. For example, in laboratory studies mental arithmetics28 and public speaking tasks29,xxx cause significantly smaller rises in eye charge per unit, blood pressure, and cortisol amidst subjects supported by some other person compared to subjects who are lone. These findings are consistent with the results of a study conducted by Steptoe, et al., who reported an overall increased noradrenergic and HPA reactivity in solitary individuals.31
The brain mechanisms, including the neural circuits and neurotransmitter systems, that underlie the acquisition and processing of social data are extremely circuitous and far from being completely understood. However, animal studies indicate that the regulation of social zipper and promotion of positive social interactions may be heavily dependent on 2 neuropeptides known equally oxytocin and vasopressin.32 Oxytocin is critical for learning social cues and has been shown to enhance maternal care in rats.33 Differential oxytocin and vasopressin receptor expression patterns in specific areas of the brain (ventral pallidum and medial amygdala) have been shown to influence the blazon and duration of social attachments formed by voles. For example, montane voles typically avoid social contact except while mating; they have lower levels of oxytocin receptors in the nucleus accumbens compared to prairie voles, which are highly social and typically monogamous.34 Oxytocin also exerts anxiolytic effects that are associated with attenuated secretion of corticosterone in lactating rodents.35
The role of oxytocin in human social beliefs has been investigated also. The Trier Social Stress Test is a laboratory stressor that involves simulation of an aversive job interview and public speaking with negative feedback, resulting in a robust increase in anxiety and salivary cortisol. Both oxytocin and social back up reduced anxiety in healthy men undergoing this procedure.36 Interestingly, the same study showed that subjects who received the combination of oxytocin and social support had the least amount of feet and lowest cortisol responses to stress. Taken together, these results advise that oxytocin promotes social beliefs and may inhibit the HPA axis reactivity to stress.
The Impact of Social Support on Wellness Outcomes
Social isolation and depression levels of social support accept been shown to be associated with increased morbidity and mortality in a host of medical illnesses. For instance, in the well-known Alameda County Studies, men and women without ties to others were ane.nine to iii times more likely to die from ischemic middle disease, cerebral vascular disease, cancer, or a host of other diseases within a nine-year period compared to individuals with many more social contacts.37 The result of social back up on life expectancy appears to be as strong as the effects of obesity, cigarette smoking, hypertension, or level of physical activity.25
Numerous epidemiological studies have reported that poor social support is associated with the onset and relapse of depression,38 negative treatment response to dysthymia,39 seasonality of mood disorder,40 and the presence of low comorbid in several medical illnesses, such every bit multiple sclerosis,41 cancer,42 and rheumatoid arthritis.43
The Vietnam War may serve as an important example of failed social support during times of high stress and trauma. Johnson and colleagues constitute that many Vietnam veterans experienced homecoming every bit a highly stressful experience.44 These veterans reported "being insulted, feeling angry, resentful, and alone." In this cohort of treatment-seeking, outpatient veterans with PTSD, homecoming stress was the strongest predictor of the frequency and intensity of their PTSD symptoms. The authors concluded that the lack of social support confirmed the veterans' perception of rejection and lead to feelings of detachment.44
In contrast to low social support, high levels appear to buffer or protect against the total affect of mental and physical disease. The human relationship between proficient social support and superior mental and physical health has been observed in various populations, including higher students, unemployed workers, new mothers, widows, and parents of children with serious medical illnesses.45
Potent social support has been shown to be an important factor in decreasing functional damage in patients with low46 and in increasing the likelihood of recovery.47 Further, the risk of developing PTSD upon exposure to combat trauma is inversely correlated with social support. For case, Boscarino, et al.,48 afterwards controlling for trauma exposure, found that Vietnam veterans with high levels of social back up were 180-percent less likely to develop PTSD as compared to those with low levels of social support.
Conclusion
The literature reviewed above conspicuously demonstrates the harmful consequences of poor social support and the protective furnishings of having access to rich and functional social networks on maintaining physical and psychological health. The verbal biopsychosocial mechanisms underlying the positive influence of social support on resilience to stress are unknown. There is undoubtedly a complex interplay of diverse environmental and genetic factors that mediate the effects of social support on health outcomes. Evidence for such a factor-environment interaction involving social back up comes from a pioneering study by Kaufman and her colleagues who accept shown that social support may confer resilience to stress by moderating genetic risks for low in maltreated children.49 In this study, the combination of the met allele of the brain-derived neurotrophic factor (BDNF) cistron and the 2 brusque alleles of the serotonin transporter (5-HTT) gene predicted the highest depression scores in maltreated children; and this vulnerability was chastened by the presence of social support.49 This of import finding demonstrates that an individual's environment may exist modified to attenuate his or her genetic adventure for developing mental illness even in the presence of environmental stressors, possibly past modifying gene expression. In fact, animal studies suggest maternal care tin modify the expression of the glucocorticoid receptor cistron via affecting DNA methylation and chromatin construction.l
Dampening HPA activity may exist another major machinery through which social support enhances resilience to stress. In fact, findings from animal and translational studies reviewed to a higher place prove that social support reduces stress-induced cortisol release. It is possible that stress-induced oxytocin release augments social amalgamation, which in plough reduces negative appraisals and arousal. Information technology is open up to speculation whether social support affects DHEA and/or NPY levels, which may and so assist to regulate HPA and noradrenergic systems, respectively.
In summary, social support seems to moderate genetic and ecology vulnerabilities for mental illness, maybe by furnishings through other psychosocial factors, such every bit fostering constructive coping strategies, and through furnishings on multiple neurobiological factors. It volition be important for psychiatric researchers to conceptualize, test, and apply effective interventions specifically aimed at increasing social support for psychiatrically ill or at-gamble populations. This represents an of import challenge for our field.
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