Rise Above Stress with These Research Backed Principles!

This post will explore the concept of stress resilience. How much of our ability to resist the negative effects of stress is determined by our genetics versus our lifestyle? I found some fascinating aspects about stress, anxiety and resilience in the research literature. I will also discuss recent findings from research for boosting resilience against the negative effects of stress.

An excellent resource that provided some of the inspiration for this post can be found here.

It is well known that stress plays a role in the development of both mental and physical illness (Weber, Lorenz, & Hemmings, 2019). Stress, anxiety, and depression account for a significant and increasing impact on workplace absenteeism (Weber et al., 2019). Stress and stress related illnesses appear to be increasing in numerous first world countries (Ozaki, Motohashi, Kaneko, & Fujita, 2012). Chronic or repeated stress plays a role in (McEwen, 2012):

• the development of heart disease and chronic hypertension
• increased inflammation and potentially inducement or exacerbation of autoimmune diseases
• increased blood clotting risks (increasing risk therefore of heart attack and stroke)
• potentially decreased bone density due to effects of chronic cortisol elevation
• fatigue, anxiety, irritability and other negative mood states
• more rapid signs of aging such as cognitive and physical ability declines
• impaired functioning and even destruction hippocampus cells in the brain leading to decreased memory formation ability
• increased susceptibility to infection, increased severity of acquired infections, and general suppression of immune system functioning

Chronic stress is bad, but escape is not always an option…what about resilience?

Frequently, posts are focused on ways to reduce stress in our daily lives. Stress reduction where possible is a reasonable approach as PART of a more comprehensive strategy. However, the reality is that life is stressful, and stress can not truly be eliminated. Cultivating increased resilience to stress–the ability to resist the negative physical and mental impacts of stress–is of growing interest (Weber et al., 2019). While much of the following research focuses on soldiers before and after combat, research also indicates that daily life stressors experienced by non-combatants activate the same neuro-physiologic pathways (Bennett et al., 2018). In other words, stress whether from acute traumatic events or from daily life stressors can have similar effects within the body.

Research findings on resilience against stress

What is resilience exactly? Current research evaluates several examples (Bennett et al., 2018):

• Emergent resilience: People that “beat the odds.” Emergent resilience is demonstrated when individuals overcome extreme and long-lasting stressful circumstances such as a childhood spent in poverty or being subjected to abuse–yet the individuals rise out of their horrific circumstances to become healthy and successful.
• Resilience behaviors: Unlike emergent resilience (which involves chronic exposure to severe stressors), this type of resilience is displayed when individuals experience a traumatic event. People who are exposed to war, terrorism, death of a parent or a spouse, or other serious traumatic events have demonstrated wide variances in their responses. Why do some people maintain mental and physical health after serious events, while others experience a loss of mental and physical health despite experiencing similar amounts of trauma?
• Minimal impact resilience: People demonstrating minimal impact resilience recover VERY quickly, maintaining their mental and physical health in spite of a traumatic experience.

Why are some people crushed by trauma and stress, while others emerge from it seemingly unscathed? For those that do suffer a loss of health initially but then recover, what makes them different from those that never recover? Is it all genetics? Or are there factors within our control?

Resilience: is it all in the genes? What about lifestyle?

With stress playing such a prominent role in long term health outcomes, as well as impacting our ability to meet our day to day obligations and duties, who wouldn’t want more resilience? When we face serious life stressors, wouldn’t we all like to be able to get through it maintaining our mental and physical health? Resilience, like many things, appears to have factors that are within our control and factors that are outside our control. The good news is that even if we have a genetic predisposition for being more susceptible to stress, there may be things we can still do to boost our resilience against stress.

Genetic factors

Genetic factors have been identified that appear to predict risk for post traumatic stress disorder or PTSD (a disorder that occurs following a traumatic event characterized by overwhelming anxiety, flashbacks, hopelessness and other distressing symptoms). Longitudinal studies (studies that follow groups of people over long periods of time) followed soldiers prior to and after experiencing combat traumas over a period of time and identified genetic differences that appeared to predict higher risk for PTSD or protection against PTSD (Snidjers et al., 2018).

Are you an anxious person by nature?: Genetic variations among the genes that regulate serotonin and dopamine appeared to predict protection against PTSD or risk for PTSD respectively (Snidjers et al., 2018). Surprisingly, a study of 1,085 soldiers showed those that had a genetic predisposition for anxiety and depression in daily life (via the ss/sl genetic variation of their serotonin coding gene), and displayed greater “threat vigilance” prior to combat, actually proved to be more resilient than non-anxious soldiers against PTSD after experiencing actual combat!! (Snidgers et al., 2018). An interesting article in the Jerusalem Post discusses this surprising research finding and potential treatment implications (Siegel-Itzkovich, 2013).

Some sensitivity is a good thing? Turns out some degree of anxiety may be protective in another way. Researchers note that people with the opposite nature, one of calm and low arousal levels, are more likely to be obese and have type 2 diabetes (Bennett et al., 2018). Stress can be a motivator to take necessary action, including actions to protect your health and well-being!! For those that explain away stressors too easily and too quickly, they may do the same following a health scare. Thus, by failing to take action and downplaying risks, they place themselves at risk of further harm. The goal is a balanced state, where stress can motivate positive action, yet not paralyze a person with fear.

The impacts of the serotonin gene variant ss/sl on predicting anxiety has been inconsistent across races and nations (Ming, Zhang, Wang, Zhu, & Yao, 2015). Further, it appears those people with the genetic variant that puts them at risk for anxiety and depression ALSO benefit more than other gene variants when exposed to a positive environment (van Ijzendoorn, Belsky, & Bakermans-Kranenburg, 2012). Genetics and stress susceptibility have proven inconsistent in research (Ming et al., 2015), suggesting there are many factors outside our genetics that make us susceptible to stress or contribute to stress resilience. This is GOOD NEWS!!! IT APPEARS OUR GENES may only play a partial role in stress susceptibility!!!

Epigenetic factors: Our genes are influenced by our lifestyle

Epigenetic factors, factors which can turn segments of our genes “on or off,” have been shown during prospective research studies (studies where a group was followed prior too and after a traumatic event involving combat) to influence risk for developing PTSD after facing trauma. Epigentics are influenced by LIFESTYLE factors!! (Alegría-Torres, Baccarelli, & Bollati, 2011). Lifestyle factors shown to influence epigenetics include diet, obesity, exercise, smoking, stress, alcohol consumption and altered sleep patterns among others (Alegria-Torres et al., 2011).

In other words, how we live can influence how genetic traits within our DNA become active or repressed!!! Nutrition factors including plant-based polyphenols (such as curcumin from turmeric, resveratrol from grape skins, and epigallocatechin-3-gallate from green tea) have been shown to impact the expression and inhibition of various genes in ways that promote protection from disease. Epigenetics research is an emerging focus. There is still much to be learned regarding how lifestyle and our genes interact to influence our physical and mental health. The above findings support the notion that despite our genetics, we can influence to some degree how our genes themselves manifest in terms of our mental and physical health outcomes.

Inflammation predicted stress vulnerability

Research also supporting the notion of lifestyle and genetic interplay in terms of stress resistance involves prospective studies where elevated inflammatory markers such as c-reactive protein (or CRP) measured prior to deployment strongly predicted higher rates of PTSD after combat exposure (Snijders et al., 2018). Elevated levels of inflammation are believed to play a role in experiencing depression and poorer mental health as well (Lai, Hiles, Bisquera, Hure, McEvoy, & Attia, 2014). Increased cytokine levels (pro-inflammatory substances produced immune cells) were likewise associated with greater occurrences of PTSD (Snijders et al., 2018).

Interestingly, diets known to reduce inflammation have been shown to be potentially protective against anxiety and depression. Further, people already suffering with anxiety and depression have shown varying degrees of improvement when changing from a pro-inflammatory diet to a more plant-based/ whole foods type diet. I cover the connections between diet and anxiety in my post “Anxiety, Depression, and Diet Connections — Current Evidence.”

Neuropeptides and resilience

Low levels of neuropeptide Y have been linked to a lower ability to cope with stress (Bennett et al., 2018). What is neuropeptide Y? Glad you asked!!

First, neuropeptides are chemical messengers used in the body for communication between nerve cells, and they are secreted by nerve cells (Burbach, 2011). Neuropeptide Y’s job is to prevent our sympathetic “fight or flight” nervous system from getting overly stimulated. It other words, it serves to calm down our “nerves” when they are overstimulated (Bennet et al., 2018).

Clearly then, if feeling overly stressed or “frazzled” is a problem for you, then you may be running low on this specific neuropeptide (Bennet et al., 2018). In fact, neuropeptide Y has demonstrated powerful fear and anxiety extinguishing effects and may prevent the storage of fear inducing memories (Comeras, Herzog, & Tasan, 2019). Interestingly, neuropeptide Y increases with fasting and hunger and decreases with elevated insulin levels and releases of the hormone leptin from fat tissue in well fed animals (Comeras et al., 2019).

From a survival standpoint, this makes sense. If an organism is well fed, it does not need to take risks to survive at that moment (Comeras et al., 2019). As such, survival mechanisms such as risk avoidance and vigilance (anxiety), and hoarding behaviors increase. On the other hand, as hunger increases, an organism has to venture out into the risky environment to seek food. Fear and the avoidance of risks decreases and the organism leaves its area of safety to seek out food (Comeras et al., 2019).

Research is evolving concerning neuropeptides and their role in fear and anxiety (Comeras et al., 2019). It has been noted that many neuropeptides interact to increase or reduce anxiety. Neuropeptides associated with feeding or being well fed have demonstrated anxiety producing effects, whereas neuropeptides released during fasting appear to have anxiety reducing effects (Comeras et al., 2019).

In the scriptures, fasting is often associated with periods of mourning. It makes sense. Fasting may be a means of boosting stress fighting neuropeptides, such as neuropeptide Y. It needs to be cautioned however that the interplay of neuropeptides is extremely complex, and the studies are still evolving. Genetic factors and epigentic factors appear to also influence levels of neuropeptides (Bennett et al., 2018; Comeras et al., 2019).

Hormones: Baseline levels inconsistently predict stress vulnerability

Baseline levels of hormones such as cortisol, oxytocin, and vasopressin have been studied in relation to succumbing to stress and development of PTSD (Snijders et al., 2018). There has been some research noting decreased baseline cortisol levels prior to a traumatic experience are predictive of development of PTSD. Other research has found no predictive association between baseline cortisol and PTSD (Snijders et al., 2018). Research regarding vasopressin and oxytocin levels and PTSD have not demonstrated a relationship (Snijders et al., 2018).

Our thought patterns can impact our resilience

How we interpret a situation has been shown to impact our stress response (Bennett et al., 2018). Coping skills and our ability to regulate our emotions have been linked to our flexibility in adapting to stressful situations. Coping skills have been shown to improve with practices such as positive psychology, mindfulness training, and development of new skill sets (Bennett et al., 2018). Those that are resilient have tendencies to utilize a more positive perspective when encountering life challenges (Li, Eschenauer, & Persaud, 2018)

Optimism: Having a belief that good things will happen in the future–having a hope for better things–has been linked to improved psychological health even in adverse circumstances (Terte, Stephens, & Huddleston, 2014). Optimism can be learned, even if you are not necessarily predisposed to it!! (Terte et al, 2014). Further, optimism has been linked to better physical health, greater adaptive coping skills, and a greater ability to deal with a variety of stresses. Finally, optimism is associated with adoption of other health promoting behaviors, such as exercise, healthy eating, avoidance of excessive alcohol intake, and avoidance of smoking. This further boosts mental and physical health (Terte et al., 2014).

Mindfulness meditation has been found to improve gray and white brain matter density in various regions of the brain including the right basolateral amygdala, brainstem regions of the pontine tegmentum, locus coeruleus, and nucleus raphe, among other brain regions (Snijders et al., 2018). These areas of the brain are involved in the creation and release of serotonin and adrenaline (Singleton, Hölzel, Vangel, Brach, Carmody, & Lazar, 2014). Changes in these brain regions also correlated with improved psychologic wellness assessment scores (Singleton et al., 2014).

Yogic meditation and deep relaxation exercises have been shown to reduce inflammation levels and impact epigenic gene expressions linked to stress pathways (Snijders et al., 2018). Research in areas of meditation and relaxation exercises are hampered by small sample sizes and great variation in types of mediation and relaxation techniques employed (Snijders et al., 2018). However, results are promising as both physical changes have been observed–brain structure changes, measurable changes in inflammatory proteins, and changes in enzymes such as telomerase–as well as perceived changes experienced directly as reported by participants (Singleton et al., 2014; Snijders et al., 2018).

Cognitive behavioral therapy (CBT) with a trained psychotherapist can boost the coping ability of a person through development of personalized plans that reinforce and enhance inherent traits necessary to reduce the impacts of stress (Snijders et al., 2018). Cognitive/ thought processing of stressful events may be influenced by certain interventions. For example, higher demands placed on the visual and spacial areas of the brain following a traumatic event may reduce visual memories of that traumatic event (Snijders et al., 2018).

Another popular CBT approach involves stress inoculation therapy, in which a person is guided through visualizing stressful events and working through those events with the help of a therapist. Relaxation tactics are incorporated into imagined scenarios that otherwise cause stress and tension. These events are then increased in terms of stress intensity over time (Snijders et al., 2014). The goal is to allow a person to adapt to handling greater intensities of stress while in a safe environment . Further, the therapist helps the subject identify coping mechanisms to help them through the stress. Such an approach has been used successfully in mitigating workplace stress (Snijders et al., 2014).

It appears that adaptation to stress with repeated exposures may only be a partial response and may not occur for everyone. For example, research sited in Bennet et al (2018) found that approximately 1 out of 3 persons did not show a decrease in their cortisol levels after repeat exposures to a stressors. For the remaining 2/3rds of participants, repeat stress exposure did result in a lower cortisol response with the second and third stress exposures, but….total adaptation did not occur even for those participants with lower cortisol levels.

For example, repeated stressors caused continued increases in heart rate, blood pressure, and adrenaline levels in all persons studied regardless of whether their cortisol levels dropped with repeat stress exposures. Inflammatory proteins also appear to remain elevated in response to real life stressors even in individuals highly experienced with the stressors (Bennet et al., 2018). In other words, simply exposing yourself to a stress situation over and over expecting that you will “get used to it” without adopting other coping mechanisms does not appear to be an effective approach.

Social support can enhance resilience

When evaluating whether stressors are addressed through problem solving (a desired trait of resilience) versus avoidance, social support has proved to be a two-edged sword (Li et al., 2018). As stressors increased, participants in research showed an increased seeking of social support. Some research has shown that social support can enhance the resilient trait of problem solving.

In other cases, social support did nothing to impact a person’s ability to problem solve. Nor did it decrease undesirable avoidant behavior (Li et al., 2018). The researchers noted that social support may help or hurt a person’s ability to problem solve. Ideally, social support should be sought for help solving problems as opposed to affirming avoidance of dealing with problems (Li et al., 2018). In other words, if your friends or social connections are simply encouraging negative behavior, it will not increase your ability to effectively address problems in your life!!!

In terms of protecting a person’s sense of physical health and psychological health, social support has been repeatedly demonstrated to play a positive and protective role (Lee & Dik, 2017). Positive support from family, friends and romantic partners can consist of advice, care during times of hardship, provision of financial or other necessities when needed, positive reinforcement, and empowerment. Finding places to build such relationships such as at places of employment, faith-based communities, volunteer opportunities or joining various community organizations all offer opportunities to find and nurture a mutually supportive social network.

Physical activity: Exercise and movement

Research has demonstrated decreased depression symptoms and improved mental health in those that exercise routinely (Kettunen, Vuorimaa, & Vasankari, 2015). A study using exercise as an intervention for 338 working adults during a 12 month period evaluated the outcomes of an exercise intervention that consisted of exercising 3-5 times per week (walking, skiing, biking) along with 2 coached sessions per month. These individuals had a PERSONALIZED program developed for them based on their current fitness levels. A control group of 33 participated in surveys along with the exercise group throughout the study duration concerning stress levels. A follow up was then conducted one year after the exercise intervention.

Stress symptoms were reduced by an average of 16% in the exercise group while the non-exercise control group saw no changes in their stress symptoms (Kettunen et al., 2015). A full year later after the initial 12 month intervention, stress reductions were still found to be 13% lower than the participants’ pre-exercise baseline. Perhaps more interesting, those that rated their stress levels the highest prior to the exercise intervention achieved the greatest stress relief by the exercise intervention, with an average of a 26% reduction on their stress symptom index score.

Not only that, but a mental resource index was measured for both groups (a measure of confidence, sense of having energy, and a sense of success completing tasks) found improvements for those that exercised (Kettunen et al., 2015). Workers participating in the exercise group saw a small increase of 5% whereas the control groups saw no improvements. However, those with the lowest scores prior to exercise improved the most, seeing their confidence levels and energy levels increase by nearly 20%! (Kettunen et al., 2015). Here too, the increase was maintained a year later after the initial 12 month intervention had been completed.

Additionally, the exercise group saw increases in their leisure time activity levels of 71%, as well as a mild increase in cardio respiratory fitness (Kettunen et al., 2015). So, more confidence, less perceived stress, reports of boosted energy levels with the highest amounts impacting those that were the most stressed to begin with? Hard to see a downside in this.

A systematic review of 42 studies involving 2187 adults likewise found that aerobic exercise tends to improve psychological sense of well-being in the majority of the studies (28 of the 42 studies), sometimes profoundly (Elkington, Cassar, Nelson, & Levinger, 2017). Several studies showed no effect, and 2 studies found a worse effect regarding sense of well-being. The same occurred when measuring psychological distress symptoms, with 15 studies showing a reduction in psychological distress up to 39%, while 4 studies showed a worsening of psychological distress following aerobic exercise. Another 4 studies showed no effect regarding aerobic exercise and psychological distress (Elkington et al., 2017).

The same mixed results occurred for resistance training and aerobic plus resistance combination training (Elkington et al., 2017). The authors noted, interestingly enough, those that were obese and least active prior to exercising were the ones that experienced increases in psychological distress. Those that had body weights within normal limits experienced greater psychological benefits. The authors posited that those that experienced higher psychological distress following exercise were those that had not exercised in recent history.

Let’s face it, exercise can be a tough habit to get into if you haven’t done it for a while. In the first study listed above, the higher success rates in my view may have been due to the exercise program being customized to each persons’ own individual fitness level. An option may be to find a form of movement/ exercise that you can personally do and feel successful at, starting slow and then building from there as you are able to do so (to avoid frustration and distress as noted by some research participants).

Finally, in terms of stress management, exercise such as yoga and pilates may prove to be an effective approach. These programs frequently emphasize deep breathing and focus which can lower physical arousal levels and heart rate (Snijders et al., 2014). Disclaimer: those with histories of injury, those taking medications and/ or with or those at risk for serious medical illnesses should consult their physician before starting any exercise program.

A sense of purpose and altruism

In a study of over 1,000 workers in Japan, those that saw themselves as positively contributing to society had significantly lower rates of psychological distress (Ozaki et al., 2012). This finding held true regardless of job status or pay rate. Workers who had supportive coworkers, supervisors and families as well as a greater sense of control over their work environment were more likely to feel a positive sense of contributing to society. As their sense of workload increased, this positive sense of contributing to society decreased.

A sense of purpose has been found to have the following benefits according to numerous studies (as cited in Snijders et al., 2018):

• Greater sense of satisfaction with life
• Lower anxiety and depression
• Lower rates of suicidal thoughts
• Higher economic status
• Higher social status
• Better general health status

A literature review of elders who displayed altruistic behaviors helping others such as friends, relatives and neighbors found the following benefits (Kumar, & Dixit, 2017):

• 50% reduction of risk of death during a 5 year study period
• Lower chance of developing depression for those experiencing loss of a spouse
• Volunteering led to greater protection from death during study periods then high religious involvement or perceived support from others
• Greater sense of happiness

Researches analyzing data from a survey of nearly 3,000 people conducted by the University of Chicago found a moderate correlation showing as charitable behaviors increased, sense of well being increased as well (Woodyard & Grable, 2014).

Religion and spirituality

Research comparing a total of 80 individuals for physical and psychological health indicators found those reporting higher levels of spiritual beliefs and a sense of spiritual well being noted the following benefits (Lawler & Younger, 2002):

• Lower mean arterial pressure and lower diastolic blood pressure (which improved with increased worship frequency)
• Lower frequencies of negative mood states
• Lower self reports of symptoms of physical illness by approximately 20%
• Lower use of medications by approximately 15%

Separate research found a moderate correlation between having a religious orientation and an improved sense of well being (Woodyard & Grable, 2014). Those that identified as having a religious orientation were also more likely to exhibit charitable behaviors (Woodyard & Grable, 2014). Finally, involvement in religious practices has been found to be more protective in terms of improved health, sense of well being, and charitable giving than simply identifying with a religious denomination (Woodyard & Grable, 2014). Said simply, just claiming you’re a “this” or a “that” when it comes to religion does not offer the same protections as actually practicing the religion.

Interestingly, many of the tools for building resilience as noted above can be found within the pages of the scriptures. For a look at how wisdom of the scriptures matches recommendations found in the modern scientific literature, see my post “Stress, Science, & Scriptures.”

Summary

In summary, genetic factors do influence how we experience stress and its negative effects but only to a limited degree. Research is demonstrating various lifestyle choices and practices also significantly impact how stress impacts us mentally and physically. Protective factors boosting resilience appear to include: diet and lifestyle choices that impact our genetic expression positively and decrease our inflammation levels, having or developing an optimistic outlook, having positive social connections and resources, physical activity, meditation and others.

Charitableness, perceiving a purpose in life, feeling that you contribute positively to society and supporting others are additional social factors that appear to boost resilience. A sense of spiritual content and participation in religion positively influence our ability to resist stress. Factors critical to our survival as a species may also influence our resilience as noted by research on neuropeptide responses to fat tissue hormones, food intake, fasting, and their subsequent impact on risk avoidance versus risk taking behaviors. The research is expanding our views on resilience, showing that far from simply being a personality trait “you either have or you don’t,” resilience is a trait that can be cultivated and enhanced!!

Thanks for reading, hope you enjoyed this post! Feel free to leave a comment, and check out my ever growing list of health related articles at donovancarper.com. Thanks!

Related posts

Stress & Anxiety can be…Good?

Stress, Science, & Scriptures

Anxiety, Depression, and Diet Connections — Current Evidence

References

Alegría-Torres, J. A., Baccarelli, A., & Bollati, V. (2011). Epigenetics and lifestyle. Epigenomics, 3(3), 267–277. doi:10.2217/epi.11.22

Bennett, J. M., Rohleder, N., & Sturmberg, J. P. (2018). Biopsychosocial approach to understanding resilience: Stress habituation and where to intervene. Journal of Evaluation in Clinical Practice, 24(6), 1339–1346. https://doi-org.lopesalum.idm.oclc.org/10.1111/jep.13052

Burbach, J. P. (2011). What are neuropeptides? Methods in Molecular Biology, 789, 1-36. doi: 10.1007/978-1-61779-310-3_1

Comeras, L. B., Herzog, H., & Tasan, R. O. (2019). Neuropeptides at the crossroad of fear and hunger: a special focus on neuropeptide Y. Annals of the New York Academy of Sciences, 1455(1), 59–80. doi:10.1111/nyas.14179

Elkington, T. J., Cassar, S., Nelson, A. R., & Levinger, I. (2017). Psychological responses to acute aerobic, resistance, or combined exercise in healthy and overweight individuals: A systematic review. Clinical Medicine Insights. Cardiology, 11, 1179546817701725. doi:10.1177/1179546817701725

Kettunen, O., Vuorimaa, T., & Vasankari, T. (2015). A 12-month exercise intervention decreased stress symptoms and increased mental resources among working adults – Results perceived after a 12-month follow-up. International Journal of Occupational Medicine & Environmental Health, 28(1), 157–168. https://doi-org.lopesalum.idm.oclc.org/10.13075/ijomeh.1896.00263

Kumar, A., & Dixit, V. (2017). Altruism, happiness and health among elderly people. Indian Journal of Gerontology, 31(4), 480–496. Retrieved from http://search.ebscohost.com.lopesalum.idm.oclc.org/login.aspx?direct=true&db=a2h&AN=126429863&site=ehost-live

Lai, J. S., Hiles, S., Bisquera, A., Hure, A. J., McEvoy, M., & Attia, J. (2014). A systematic review and meta-analysis of dietary patterns and depression in community-dwelling adults, The American Journal of Clinical Nutrition, 99(1), 181–197, https://doi.org/10.3945/ajcn.113.069880

Lawler, K. A., & Younger, J. W. (2002). Theobiology: An analysis of spirituality, cardiovascular responses, stress, mood, and physical health. Journal of Religion & Health, 41(4), 347. https://doi-org.lopesalum.idm.oclc.org/10.1023/A:1021126510680

Lee, C. S., & Dik, B. J. (2017). Associations among stress, gender, sources of social support, and health in emerging adults. Stress & Health: Journal of the International Society for the Investigation of Stress, 33(4), 378–388. https://doi-org.lopesalum.idm.oclc.org/10.1002/smi.2722

Li, M., Eschenauer, R., & Persaud, V. (2018). Between avoidance and problem solving: Resilience, self‐efficacy, and social support seeking. Journal of Counseling & Development, 96(2), 132–143. https://doi-org.lopesalum.idm.oclc.org/10.1002/jcad.12187

McEwen, B. S. (2012). Protective and damaging effects of stress mediators. The New England Journal of Medicine, 338(1), 171-179. Retrieved from https://pdfs.semanticscholar.org/ee3c/1a87d21b1865abe72157226e38103b0d95cf.pdf

Mayo Clinic. (2019). Post-traumatic stress disorder. Retrieved from https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967

Ming, Q., Zhang, Y., Yi, J., Wang, X., Zhu, X., & Yao, S. (2015). Serotonin transporter gene polymorphism (5-HTTLPR) L allele interacts with stress to increase anxiety symptoms in Chinese adolescents: a multiwave longitudinal study. BMC psychiatry, 15, 248. doi:10.1186/s12888-015-0639-y

Ozaki, K., Motohashi, Y., Kaneko, Y., & Fujita, K. (2012). Association between psychological distress and a sense of contribution to society in the workplace. BMC Public Health, 12(1), 253. https://doi-org.lopesalum.idm.oclc.org/10.1186/1471-2458-12-253

Siegel-Itzkovich, J. (2013). ‘Threat vigilance’ can also help reduce risk. Retrieved from https://www.jpost.com/Health-and-Science/Threat-vigilance-can-also-help-reduce-risk

Singleton, O., Hölzel, B. K., Vangel, M., Brach, N., Carmody, J., & Lazar, S. W. (2014). Change in brainstem gray matter concentration following a mindfulness-based intervention is correlated with improvement in psychological well-being. Frontiers in human neuroscience, 8, 33. doi:10.3389/fnhum.2014.00033

Snijders, C., Pries, L. K., Sgammeglia, N., Al Jowf, G., Youssef, N. A., de Nijs, L., … Rutten, B. (2018). Resilience against traumatic stress: Current developments and future directions. Frontiers in psychiatry, 9, 676. doi:10.3389/fpsyt.2018.00676

Terte, I., Stephens, C., & Huddleston, L. (2014). The development of a three part model of psychological resilience. Stress & Health: Journal of the International Society for the Investigation of Stress, 30(5), 416–424. https://doi-org.lopesalum.idm.oclc.org/10.1002/smi.2625

van Ijzendoorn, M. H., Belsky, J., & Bakermans-Kranenburg, M. J. (2012). Serotonin transporter genotype 5HTTLPR as a marker of differential susceptibility? A meta-analysis of child and adolescent gene-by-environment studies. Translational psychiatry, 2(8), e147. doi:10.1038/tp.2012.73

Weber, S., Lorenz, C., & Hemmings, N. (2019). Improving stress and positive mental health at work via an app-based intervention: A large-scale multi-center randomized control trial. Frontiers in psychology, 10, 2745. doi:10.3389/fpsyg.2019.02745

Woodyard, A., & Grable, J. (2014). Doing good and feeling well: Exploring the relationship between charitable activity and perceived personal wellness. Voluntas: International Journal of Voluntary & Nonprofit Organizations, 25(4), 905–928. https://doi-org.lopesalum.idm.oclc.org/10.1007/s11266-013-9382-5