Despite these definitional differences, decades of research have identified psychological factors that promote resilience to trauma and severe adversity. Some widely replicated and potentially modifiable factors include effective emotion regulation, positive emotionality, cognitive flexibility and control, facing fears and active coping, and ability to harness social support [reviewed in (Seeley, Boukezzi, DePierro, Charney, & Feder, 2023; Southwick et al., 2023)]. Effective emotion regulation is associated with higher executive control and supports adaptive coping. Facing fears, likely facilitated by successful fear extinction plus cognitive flexibility, allows for critical appraisal of threats and active coping via tackling stressors or problem solving. Positive emotions and related reward system function also promote resilience by supporting positive reframing and the ability to harness social support, which in turn serves as a safety net and facilitates stress recovery. The ability to harness social support draws partly on competent social cognition – capacity to accurately ‘read’ and respond to others’ intentions of others – making social cognition a potential resilience-linked factor.

Building on work identifying core psychological factors associated with resilience (Feder et al., 2019; Seeley et al., 2023; Southwick et al., 2023) and previous neuroimaging resilience reviews in adults and/or youth (Méndez Leal & Silvers, 2021; Moreno-López et al., 2020; van der Werff, van den Berg, Pannekoek, Elzinga, & Van Der Wee, 2013), our narrative review covers human fMRI studies of neural circuitry underlying psychological factors associated with resilience to trauma and severe adversity. We organize fMRI studies around emotion regulation, reward responsivity, and cognitive control, e.g. (Dennison et al., 2016; Holz, Tost, & Meyer-Lindenberg, 2020; Kaldewaij et al., 2021; van der Werff et al., 2013). As described above, active coping, facing fears (and related fear extinction) (Careaga, Girardi, & Suchecki, 2016), and the ability to harness social support (including competent social cognition) (Lepore & Kliewer, 2019; Stevens & Jovanovic, 2019) have also been linked to resilience, yet there are fewer resilience neuroimaging studies of them as resilience-related psychological factors. Here, we include these factors as ‘emerging areas’, as they might illuminate additional pathways to resilience and underlying neural circuitry.

Cross-sectional fMRI studies of resilient individuals typically focus on (1) youth and adults who have experienced childhood maltreatment or (2) adults exposed to trauma in adulthood including severe accidents, assaults, or occupation-related incidents (e.g. first-responders, military). In this narrative review, we only discuss cross-sectional studies with a key comparison group of healthy, non-trauma-exposed participants (in addition to resilient and symptomatic groups), because this allows researchers to disentangle effects of trauma exposure and psychopathology (see van der Werff et al., 2013). Also included are several studies of neural correlates of high trait resilience.

We focus on literature published after van der Werff et al., 2013 review. Due to recent large cohort studies and improved reporting standards for neuroimaging, this allows us to focus on better powered work. Within each section, we first cover cross-sectional findings in resilient trauma survivors (children; adults) and high trait resilience (when available). Additionally, we discuss longitudinal studies and a few available interventional studies that contribute new insights on the neural correlates of resilience. Although most studies reviewed here focus on task-based regional brain activity, we also include relevant functional connectivity findings, including resting state fMRI.

Successful emotion regulation is key in resilience (Troy & Mauss, 2011). Resilient individuals downregulate neural responses to stress or threat via medial prefrontal cortex (mPFC) inhibition of emotional reactivity in a network of brain regions, including the amygdala and anterior cingulate cortex (ACC); conversely, absent or low resilience is associated with hyperreactivity to emotional stimuli, both trauma-related and -unrelated (Patel, Spreng, Shin, & Girard, 2012; Whittle et al., 2013). In an earlier review, resilient adults (exposed to trauma in childhood and/or adulthood) showed greater mPFC engagement, including rostral ACC, and lesser activity in the dorsal ACC and amygdala, compared to symptomatic trauma-exposed adults across several studies (van der Werff et al., 2013).

Cross-sectional studies in youth with a history of childhood maltreatment show increased frontolimbic connectivity in resilient youth (Demers et al., 2018; Moreno-López et al., 2020); for example greater down-regulation of amygdala activity during emotion regulation (Schweizer et al., 2016). Higher-trait resilience youth living in adverse environments spent more time than lower-trait resilience peers in a dynamic resting state functional connectivity pattern of less salience network connectivity with both the central executive and default mode networks. This could suggest lesser influence of emotional reactivity during unconstrained thought (Iadipaolo et al., 2018).

Cross-sectional findings are bolstered by several recent longitudinal studies of early adversity. Among adopted children who experienced early institutional care, self-reported anxiety at three-year follow-up decreased more in children who showed reduced amygdala responses to images of their adoptive parents (v. strangers) at baseline (Callaghan et al., 2019). Similarly, previously-institutionalized youth showing stronger ventromedial (vm)PFC-hippocampal functional connectivity during an aversive learning task reported lower anxiety at two-year follow-up (Silvers et al., 2016). A longitudinal study of internalizing symptoms in older adolescents and youth with a childhood maltreatment history compared to propensity-matched controls found that greater baseline amygdala threat reactivity predicted later internalizing symptoms – independently of stressful life events and factors such as socioeconomic status, suggesting that lesser limbic reactivity may be a unique predictor of resilience to childhood maltreatment (Gerin et al., 2019).

Cross-sectional findings in adults are similar to those in youth. Healthy adults with a childhood maltreatment history demonstrated greater frontal inhibition of emotional distractors (Demers et al., 2021). In another study of resilient adults with a childhood maltreatment history, blunted amygdala response correlated with higher depression symptoms (Yamamoto et al., 2017). However, in Yamamoto and colleagues’ sample of healthy individuals without clinically significant symptoms, it is notable that higher amygdala reactivity was accompanied by a compensatory increase in prefrontal functional connectivity, linked to top-down emotion regulation. Studies of adulthood trauma exposure similarly suggest lesser amygdala reactivity and greater mPFC regulation in resilient adults. Lower baseline amygdala reactivity to fearful faces at 2–3 weeks post-incident was associated with lower self-reported PTSD symptoms at one-year follow-up, in individuals recruited from a hospital emergency department (Stevens et al., 2017). Another study, using Granger causality analysis, revealed more resting state mPFC inhibition of the amygdala in resilient typhoon survivors, compared to both symptomatic survivors and non-trauma-exposed controls (Chen et al., 2018).

Longitudinal work in adults links pre-exposure neural functioning to later outcomes. In a large prospective sample of police trainees, pre-exposure anterior PFC activity during an emotional action control task predicted lower PTSD symptoms at follow-up. Anterior PFC activity moderated the positive relationship between previous trauma load (a risk factor for PTSD) and PTSD symptom levels at follow-up, such that cumulative number of lifetime trauma exposures was not linked to higher PTSD symptoms in trainees with higher anterior PFC activity (Kaldewaij et al., 2021). In another cohort of police trainees scanned pre- and post-trauma exposure, those with higher post-traumatic intrusion symptoms showed increased salience network resting state connectivity after stress induction (Zhang et al., 2022). Together, these studies suggest that prefrontal regulation of limbic reactivity to emotional threat cues may predict resilience to posttraumatic stress and anxiety symptoms. In Kaldewaij et al. (2021), amygdala reactivity appeared to be acquired, rather than a prospective marker of PTSD vulnerability. However, previous longitudinal studies linked stress vulnerability to higher baseline amygdala reactivity (Admon et al., 2009; Swartz, Knodt, Radtke, & Hariri, 2015). Longitudinal prospective cohort studies, such as the ongoing Advancing Understanding of Recovery After Trauma (AURORA) study (McLean et al., 2020), which follows patients scanned 2–3 weeks after visiting the emergency department posttrauma, hold promise for a more granular understanding of emotional responding in resilience. Notably, there may be multiple pathways to risk/resilience: cross-task cluster analysis in an AURORA cohort, replicated in a different cohort with a wider range of trauma exposures, identified two vulnerability-related ‘biotypes’ characterized by heightened emotional reactivity to threat, but differential reactivity to reward, detailed in a later section (Stevens et al., 2021).

From an interventional perspective, a pilot trial of fMRI-guided real-time neurofeedback training decreased amygdala activation and increased amygdala-vmPFC connectivity in combat veterans, but was not superior to sham in reducing PTSD symptoms (Zotev et al., 2018). However, training a predeployment military sample to downregulate EEG-derived amygdala signal successfully decreased amygdala BOLD signal and increased amygdala-mPFC functional connectivity at follow-up (Keynan et al., 2019). Active training improved experimental emotional regulation indices, but had no effect on self-reported anxiety (Keynan et al., 2019). Neurofeedback training represents a step toward developing new interventions for at-risk individuals. However, whether this approach will be effective in preventing or mitigating post-traumatic distress requires further study.

Cognitive reappraisal is a deliberate form of emotion regulation that buffers risk for adverse outcomes following trauma exposure (Rodman, Jenness, Weissman, Pine, & McLaughlin, 2019). The ability to re-evaluate the meaning of experiences promotes adaptation after trauma, and represents a core part of psychological interventions (Hofmann, Asmundson, & Beck, 2013). For example, in an ecological momentary assessment study in individuals remitted from depression, positive appraisal (ability to ‘focus on positive meaning’) and feelings of resilience were mutually reinforcing. Positive reappraisal was also associated with lower incidence of residual depressive symptoms (Hoorelbeke, Van den Bergh, Wichers, & Koster, 2019). Neuroimaging meta-analyses highlight ventrolateral (vl)PFC and dorsolateral (dl)PFC, dorsal ACC, and amygdala function in effortful emotional regulation in healthy individuals – and highlight functional differences in healthy v. symptomatic participants (Zilverstand, Parvaz, & Goldstein, 2017).

Laboratory studies of trauma-exposed individuals found inconsistent evidence for a link between psychological symptoms and neural activity during experimental tasks instructing participants to deliberately modulate their emotional response to affective images using cognitive reframing. A longitudinal study in maltreated youth found a relationship between prefrontal recruitment during effortful cognitive reappraisal (and associated down-regulation of amygdala reactivity to negative stimuli) and subsequent risk for mood symptoms, but no relation to anxiety symptoms (Rodman et al., 2019). In a small sample of adolescent girls exposed to violent assault, participants who responded better to trauma-focused CBT demonstrated decreased functional connectivity between the amygdala and mid-posterior insula cortex during reappraisal of negative images following treatment (Cisler et al., 2016). However, in a larger sample of adults with PTSD, regional BOLD signal during a cognitive reappraisal task was not associated with exposure-based psychotherapy outcomes (Fonzo et al., 2017). In conclusion, individual differences in ability to successfully engage active emotion regulation strategies like reappraisal may buffer against the deleterious effects of trauma exposure on mood, but are not necessarily related to changes in anxiety and PTSD symptom levels.

Responsivity to reward underlies key psychological factors linked to resilience such as optimism and positive emotionality (Feder et al., 2019). Resilient individuals show comparatively preserved ventral striatum response both when anticipating and receiving rewards, whereas PTSD and history of childhood maltreatment have been linked to anhedonia and blunted reward responses – particularly to social reward cues (Dillon et al., 2009; Elman et al., 2009; Hanson, Hariri, & Williamson, 2015; Hanson et al., 2016; Nawijn et al., 2015; Sailer et al., 2008). In a cross-sectional community-based sample of adolescents (a substantial proportion of whom had a history of severe childhood maltreatment), greater pallidal activation in response to positive images was associated with lower depression symptoms, and higher putamen activation was associated with lesser increase in depression two years later (Dennison et al., 2016). Among a large sample of university students (n = 820) in the Duke Neurogenetics Study cohort, increased ventral striatal activation to both anticipatory and consummatory reward during a card guessing game significantly weakened the relationship between childhood trauma exposure and adult anhedonia – including when controlling for other depression symptoms and recent life stress (Corral-Frías et al., 2015).

In a cross-sectional study, trauma-exposed adults without PTSD had greater ventral striatal responses to happy faces compared to those with PTSD (Felmingham et al., 2014). Amongst individuals who felt negatively affected by the outcome of the 2016 US presidential election (and belonged to historically marginalized groups), higher nucleus accumbens BOLD signal and higher mPFC-accumbens connectivity during reward receipt attenuated the relationship between election-related distress and depression symptoms (Tashjian & Galván, 2018). In a longitudinal assessment of combat-exposed paramedics, decreased reward response in the nucleus accumbens post-, but not pre-exposure, was found to be related to self-reported PTSD symptoms – suggesting that preserved reward responses may be a marker of resilience, rather than a prospective indicator (Admon et al., 2013).

While greater reactivity to rewarding social/environmental cues could promote resilience, the resilience-reward responsivity association may be more complex. The longitudinal AURORA biotypes study (Stevens et al., 2021) identified two clusters associated with resilience in adults scanned 2–3 weeks after seeking emergency department care for a serious injury or medical condition. One (a ‘high reward reactivity’ cluster with low threat reactivity and low inhibitory control) did not replicate in the test cohort. The other, replicable, cluster had low reactivity to both threat and reward, with higher hippocampal and vmPFC engagement during the inhibitory control task, suggesting that resilience is associated with better inhibition of emotional reactivity broadly. The association between resilience and lower general reactivity echoes an earlier small cross-sectional study in Special Forces soldiers – considered highly resilient individuals –, who showed lower differential nucleus accumbens and subgenual PFC responses to monetary reward v. no-reward, compared to non-trauma-exposed civilians (Vythilingam et al., 2009). These findings illustrate challenges for resilience research when trying to synthesize findings across different populations – e.g. repeated occupational trauma exposures may differ from a singular exposure, and certain occupations (like first responders) may select for traits like higher sensation-seeking and higher reactivity threshold. For example, a recent, rigorous attempt to replicate Stevens et al. (2021) AURORA biotypes identified threat- and reward-related clusters in their cohort, but these were not identical to those in AURORA and not related to PTSD vulnerability (Ben-Zion et al., 2023), potentially due to some differences in sample composition and methods.

Resilient individuals engage prefrontal and hippocampal regions during executive function tasks e.g. (Ben-Zion et al., 2018). Conversely, deficits in inhibition, working memory, attentional control, and cognitive flexibility are observed in both adults with a history of childhood maltreatment and individuals with a diagnosis of PTSD, not accounted for by comorbid psychopathology, substance use, or history of traumatic brain injury (Gould et al., 2012; Scott et al., 2015) (although the relationship between PTSD symptom severity and cognitive function may be bidirectional; Jacob, Dodge, & Vasterling, 2019). In an early study, both resilient and non-trauma-exposed healthy adults showed greater vlPFC, mPFC, and dlPFC activation during an inhibitory control task, v. those with PTSD (Falconer et al., 2008). Resilient individuals have also shown greater dlPFC and superior frontal gyrus activation during an attentional control task with emotional distractors, compared to both adults with PTSD and non-trauma-exposed controls (Blair et al., 2013). Recently, both resilient and non-trauma-exposed adults (but not adults with PTSD) exhibited significant decoupling between prefrontal regions and subcortical structures when attempting to suppress experimentally-induced memories (Mary et al., 2020): top-down prefrontal modulation of subcortical memory structures (hippocampus, parahippocampal gyrus, and precuneus) was associated with successful memory suppression, whereas the PTSD group showed bottom-up modulation of information flow. Indeed, greater whole-brain resting state hippocampal functional connectivity was a significant predictor of PTSD symptoms at six months in a prospective study in traumatically-injured adults recruited from the emergency department (Fitzgerald et al., 2022). Optimal prefrontal-subcortical cognitive control network function may facilitate resilience.

A longitudinal study in the Duke Neurogenetics Study cohort (n = 120) identified that greater neural responses to threat and reward predicted future increases in anxiety in university students with average or low but not high prefrontal activity during a working memory task, controlling for childhood maltreatment and stressful life events (Scult, Knodt, Radtke, Brigidi, & Hariri, 2019). These findings echo (Stevens et al., 2021) in suggesting that lower general reactivity and higher prefrontal inhibitory control could protect against adverse outcomes post-trauma exposure. Further, a longitudinal assessment of recently trauma-exposed adults found that increased inhibitory control-related hippocampal activation (at 1–2 months post-trauma) predicted decreased PTSD symptom severity at three and six months, and this finding was replicable (van Rooij et al., 2018). The hippocampus links cognition, memory and emotion (Speer & Delgado, 2017), thus is likely relevant to resilience to PTSD symptoms like alterations in mood, cognitive function, and intrusive thoughts and memories.

Finally, NCANDA cohort (n = 392) resting state fMRI showed that the association between childhood trauma severity and executive function difficulties in adolescents was mediated by lower functional connectivity between a network of the postcentral and precentral gyri, dorsal ACC, intraparietal sulcus, and anterior insula cortex – hub regions implicated in cognitive/behavioral control and sensorimotor integration. Preserved interconnectivity between the postcentral gyrus and dorsal ACC was related to lower reported executive dysfunction at baseline, and predicted lower likelihood of high-risk drinking 1–4 years later (Silveira et al., 2020). In addition to protecting against PTSD symptoms, preserved prefrontal function may reduce vulnerability to maladaptive coping strategies like substance use.