ARTICLE IN PRESS

Psychoneuroendocrinology (2007) 32, 11491152

Available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/psyneuen

SHORT COMMUNICATION

Factors associated with resilience in healthy adults

Daphne Simeona,, Rachel Yehudaa,b, Ruth Cunilla, Margaret Knutelskaa,
Frank W. Putnamc, Lisa M. Smitha
a

Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA
Department of Psychiatry, Bronx Veteran Affairs Hospital, Bronx, NY, USA
c
Department of Psychiatry and Pediatrics, University of Cincinnati College of Medicine and Cincinnati Childrens Hospital
Medical Center, Cincinnati, OH, USA
b

Received 9 February 2007; received in revised form 7 August 2007; accepted 13 August 2007

KEYWORDS
Resilience;
Childhood trauma;
Cortisol;
Temperament;
Stress;
Cognitive
performance

Summary
Mature defenses comprise one well-validated indicator of resilience. We investigated the
relationships of resilience to trauma, attachment, temperament, cortisol, and cognitive
performance in adult healthy volunteers. Participants were administered the Defense Style
Questionnaire; the Relationship Questionnaire; the Childhood Trauma Questionnaire, and
the Tridimensional Personality Questionnaire. Cortisol determinations included 24-h
urinary, mean hourly plasma, response to low-dose dexamethasone suppression, and
reactivity to the Trier social stress test (TSST). Mathematical performance during the TSST
was quantified. Twenty-five women and 29 men participated. Resilience was significantly
negatively correlated with childhood interpersonal trauma and with harm avoidance.
Resilience was significantly positively correlated with urinary cortisol, secure attachment,
reward dependence, and superior performance. In a linear regression analysis, the
strongest predictor of resilience was childhood trauma, followed by math performance
under stress and harm avoidance. We conclude that in young adults without manifest
psychiatric disorder, resilience was associated with developmental, biological, and
cognitive measures which merit further investigation.
& 2007 Elsevier Ltd. All rights reserved.

1. Introduction

Corresponding author. Department of Psychiatry, Box ] 1230,

Mount Sinai School of Medicine, One Gustave L. Levy Place, New
York, NY 10029, USA. Tel.: +1 212 241 7477; fax: +1 212 427 6929.
E-mail address: daphne.simeon@mssm.edu (D. Simeon).

0306-4530/$ - see front matter & 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.psyneuen.2007.08.005

Resilience, the relative capacity for healthy adaptation to

life adversities, has been increasingly identified as an
important area of both research and clinical intervention,
and its biopsychosocial substrates are becoming better
elucidated (Charney, 2004). There are different ways that
studies have defined and measured resilience, including

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overall psychosocial functioning, or measures of hardiness
and coping skills (Connor and Zhang, 2006). The absence of
major psychopathology, in and of itself, does not comprise
an adequate indicator of resilience. Mature defenses
(sublimation, humor, anticipation, and suppression) comprise one well-established model of positive mental health,
powerfully predicting psychological well-being in a community male sample followed prospectively over 45 years
(Vaillant and Vaillant, 1990), and comprising a validated
indicator of resilience (Vaillant, 2003). In the current study
of healthy volunteers, we explored the relationships
between this index of resilience and several factors that
have been implicated in healthy adaptation, namely
temperament, childhood trauma, attachment style, baseline and stress-related cortisol measures, and cognitive
performance under stress.

2. Methods
Healthy adult volunteers in this study were part of a larger
study examining HPA axis function in dissociative disorders,
PTSD, and normal control subjects (Simeon et al., 2007);
data reported here are not replicated in the prior study.
Participants were broadly recruited via newspaper advertisements and postings or were self-referred via internet
websites and other resources. They were phone screened
and, if appropriate, evaluated by a psychiatrist to determine eligibility. Inclusion criteria for healthy control
subjects were age 1860; no lifetime Axis I or II disorders,
medically and neurologically healthy; no history of head
trauma; normal baseline physical examination and routine
laboratory testing; not taking any medications for at least
2 months; negative urine toxicology testing; and negative
pregnancy testing if female. Cigarette smokers of more than
5 cigarettes daily were excluded. The study was approved by
the institutional review board, and subjects signed written
informed consent prior to evaluation.
Participants were administered following self-report measures. The Defense Style Questionnaire (Bond, 1986) has been
factor-analyzed into three levels of defenses, mature
(resilience index), neurotic, and immature. The Relationship Questionnaire rates each of four attachment styles,
secure, fearful, preoccupied, and dismissive, on a 7-point
scale ranging from 1not at all like me to 7very much
like me (Griffin and Bartholomew, 1994). The self-report
Childhood Trauma Questionnaireshort version consists of 25
items rated on a 5-point scale, measuring emotional abuse,
emotional neglect, physical neglect, physical abuse and
sexual abuse (Bernstein et al., 2003). The 100-item Tridimensional Personality Questionnaire assesses three dimensions of
temperament, novelty seeking, harm avoidance, and reward
dependence (Cloninger, 1987).
Subjects underwent inpatient determination of cortisol
levels; detailed methodology is reported elsewhere (4).
We measured 24-h urinary cortisol, as well as hourly
serial plasma cortisol from 8 am to 11 pm averaged over
the 16 time points. We also measured cortisol response to a
single oral 0.5 mg dexamethasone challenge dose. Finally,
participants underwent the Trier social stress test (TSST),
known to induce mild to moderate psychosocial stress in
healthy individuals (Kirschbaum et al., 1993). The TSST is a

D. Simeon et al.
public performance stress-induction task, and consisted of a
5-min anticipation/preparation phase and a 10-min presentation phase (a 5-min unstructured speech mimicking a
job interview and a 5-min specified math task). Peak cortisol
stress reactivity was calculated by subtracting the post-TSST
plasma cortisol level from the pre-TSST plasma cortisol
level. The TSST mathematical task consisted of subtracting
serial 13s from 1022; with every error participants were
told to restart from the beginning. During the math task we
recorded total number of errors and lowest number
reached; better performance involved making fewer errors
and/or reaching a lower number. After TSST completion,
participants rated stressor severity on a 7-point Likert-type
scale.
Relationships between resilience and other variables were
explored using partial correlations, controlling for age and
gender. Additionally, urinary cortisol analyses were controlled for body mass index and dexamethasone suppression
analyses were controlled for dexamethasone levels. Once
the variables associated with resilience were identified by
correlational analyses, they were entered into linear
regression analysis in order to determine which variables
significantly predicted resilience. All statistical analyses are
two-tailed.

3. Results
Participants were 25 women and 29 men, with a mean age of
33.2 years (SD 11.0). Resilience was fairly normally distributed in the sample (mean 5.7, SD 1.0, median 5.8,
skewness 0.20, kurtosis 0.23, range 3.68). Resilience was not significantly associated with age or gender.
Childhood trauma total score ranged from 25 to 67, with a
mean of 33.8 (SD 9.2). Trauma encountered in the sample
ranged from none at all to substantial, such as separation
from both parents for many years, witnessing frequent
chronic domestic violence, severe emotional abuse, extreme physical neglect, very frequent physical abuse, and
sexual abuse.
Resilience was strongly inversely correlated with total
childhood trauma score (r 0.43, df 48, p 0.002)
(emotional neglect: r 0.39, p 0.004; physical
abuse: r 0.37, p 0.009; emotional abuse: r 0.27,
p 0.062; sexual abuse: r 0.24, p 0.096; physical
neglect: r 0.22, p 0.134). Resilience was positively
correlated with secure attachment (r 0.29, df 50,
p 0.036), and tended to negatively correlate with
preoccupied and fearful attachment (r 0.25, df 50,
p 0.074; r 0.24, df 50, p 0.091, respectively).
Resilience was positively correlated with reward dependence (r 0.37, df 49, p 0.008) and negatively correlated with harm avoidance (r 0.29, df 49, p 0.041).
Table 1 presents the correlations of resilience with the
four cortisol measures and with the two measures of
mathematical performance under stress. Subjective stress
rating was not significantly associated with resilience,
cortisol, or performance. Of the four cortisol measures,
childhood trauma was significantly associated only with
mean plasma cortisol (partial r 0.28, df 50, p .047).
All variables significantly correlated with resilience (childhood trauma, secure attachment, reward dependence, harm

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Factors associated with resilience in healthy adults

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Table 1 Relationships between resilience, cortisol measures, and cognitive performance under stress during the Trier social
stress test in 54 healthy adults (correlation coefficients are followed by probability values in parentheses).

Resilience
Urinary cortisola,b
Plasma cortisola
Dexamethasone suppression testa,c
Trier social stress testa

Resilience

Lowest number reached

Total number of errors

0.28* (.049)
0.25 (.078)
0.01 (.971)
0.09 (.518)

0.29* (.048)
0.09 (.528)
0.21(.156)
0.04 (.771)
0.21 (.141)

0.36* (.013)
0.18 (.219)
0.20 (.167)
0.10 (.471)
0.14 (.340)

*po.05.
a
Partial correlation controlling for age and gender.
b
Partial correlation controlling for body mass index.
c
Partial correlation controlling for dexamethasone level.

avoidance, urinary cortisol, mathematical errors, and lowest

number reached) were entered into a linear regression
analysis. As a block, the seven predictors accounted for
50.4% of the total variance in resilience (F 5.36, df 7,44,
po0.001). When entered in a forward stepwise fashion,
childhood trauma was the strongest predictor of resilience
(R2 21.1%, p 0.002), followed by mathematical performance errors (change R2 17.3%, p 0.001), and subsequently by harm avoidance (change R2 9.0%, p 0.011).
The remaining four variables did not make a significant
additional contribution to the prediction of resilience.

4. Discussion
Determinants of resilience include neurobiological, genetic,
temperamental, and environmental influences (2). Our
findings present evidence for three of these domains in a
single sample of adult participants without psychiatric
disorders: temperament, attachment, childhood interpersonal trauma, urinary cortisol, and cognitive performance
under stress. In this sample, of all variables measured
resilience was most strongly associated (negatively) with
childhood trauma. Childhood adversity has been broadly and
compellingly linked to higher rates of psychiatric disorders
in adulthood (Kessler et al., 1997). Therefore it may not be
surprising that even in a psychiatrically healthy adult
sample, childhood adversity was associated with lower
resilience. This finding does not lend obvious support to
the stress inoculation theory (Rutter, 1987; Parker et al.,
2004), as even the overall modest range of childhood trauma
in our sample was negatively associated with resilience.
However, it is quite plausible that successful inoculation
may be better provided by exposure to stressful childhood
circumstances different from those of interpersonal maltreatment. Indeed, in the current sample resilience was
positively, although non-significantly, associated (r 0.13,
df 52, p 0.34) with a cumulative measure of childhood
stressful events that is mutually exclusive with the CTQ
(unpublished data, Simeon et al.). On the other hand,
greater childhood trauma has been reported in stress-hardy
Special Forces compared to general infantry soldiers, and
has been interpreted as indicative of stress inoculation
(Morgan et al., 2001).

Resilience was also positively associated with secure

attachment, in accord with reports that the presence of one
good parentchild relationship comprises a protective
mechanism (Rutter, 1987). One way in which this may
happen is by buttressing self-esteem; in healthy young
adults, high self-esteem and internal locus of control have
been associated with lower cortisol reactivity and better
arithmetic performance during psychosocial stress (Pruessner et al., 2005). Resilience also showed a relationship with
temperament dimensions, positive with reward dependence
and negative with harm avoidance, suggesting that individuals who take more risks and seek out rewards in healthy
ways may have better adaptation than those who excessively avoid. This finding is reminiscent of a positive
correlation between resilience and extraversion, and a
negative correlation between resilience and neuroticism,
reported in a sample of college students (Campbell-Sills
et al., 2006).
Higher urinary cortisol levels were associated with
resilience, and could conceivably be protective against the
development of psychopathology, even in individuals exposed
to certain degrees of adversity. Indeed, there is evidence that
low baseline cortisol levels may be a risk factor predisposing
individuals to develop psychopathology, in particular PTSD,
after traumatic exposure (Yehuda et al., 2000). Interestingly,
superior cognitive performance under stress was associated
with greater resilience, but not with cortisol stress reactivity.
Differing from our finding, another study of healthy participants found that high cortisol responders performed worse
than low cortisol responders on the mental arithmetic task of
the TSST (AlAbisi et al., 2002).
The moderate inverse relationship between childhood
trauma and mature defenses found in this study of
psychiatrically healthy adults raises the broader issue of
the relationship between vulnerability, resilience, and
psychopathology. Rutter (1987) emphasized how vulnerability and protection are distinct, rather than opposite
poles of the same concept. Resilience is neither the
opposite of psychopathology, nor the opposite of vulnerability, as has recently been empirically shown and
conceptually discussed (Yehuda and Flory, in press).
The strength of the current study lies in its rigorous
design, reasonable sample size, and the use of wellvalidated measures spanning phenomenology, biology and

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cognition. There are several limitations. First, we did not
categorically examine exposed versus non-exposed individuals. Rather we assumed that exposure to adversity occurs
on a continuum, and that therefore it is reasonable to
examine both vulnerability and resilience dimensionally.
We also did not use multiple measures of resilience tapping
different aspects of the construct (Connor and Zhang, 2006),
such as social support, self-esteem, and spiritual faith.
Finally, the design of the study was cross-sectional, rather
than tracking resilience longitudinally after the occurrence
of recent stressful life events.

Role of funding source

Supported in part by NIMH RO1 MH62414 to Dr. Simeon and
NIH MO1 RR0071 to the Mount Sinai School of Medicine
General Clinical Research Center.

Conflict of interest
None declared.

Acknowledgments
Dr. Simeon was supported in part by NIMH RO1 MH62414 and
the Mount Sinai School of Medicine General Clinical Research
Center by NIH MO1 RR0071.

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