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1.  Reliability and Validity of the Korean Version of the Connor-Davidson Resilience Scale 
Psychiatry Investigation  2010;7(2):109-115.
The Connor-Davidson Resilience Scale (CD-RISC) measures various aspects of psychological resilience in patients with posttraumatic stress disorder (PTSD) and other psychiatric ailments. This study sought to assess the reliability and validity of the Korean version of the Connor-Davidson Resilience Scale (K-CD-RISC).
In total, 576 participants were enrolled (497 females and 79 males), including hospital nurses, university students, and firefighters. Subjects were evaluated using the K-CD-RISC, the Beck Depression Inventory (BDI), the Impact of Event Scale-Revised (IES-R), the Rosenberg Self-Esteem Scale (RSES), and the Perceived Stress Scale (PSS). Test-retest reliability and internal consistency were examined as a measure of reliability, and convergent validity and factor analysis were also performed to evaluate validity.
Cronbach's α coefficient and test-retest reliability were 0.93 and 0.93, respectively. The total score on the K-CD-RISC was positively correlated with the RSES (r=0.56, p<0.01). Conversely, BDI (r=-0.46, p<0.01), PSS (r=-0.32, p<0.01), and IES-R scores (r=-0.26, p<0.01) were negatively correlated with the K-CD-RISC. The K-CD-RISC showed a five-factor structure that explained 57.2% of the variance.
The K-CD-RISC showed good reliability and validity for measurement of resilience among Korean subjects.
PMCID: PMC2890864  PMID: 20577619
Connor-Davidson Resilience Scale; Posttraumatic stress disorder; Resilience; Reliability; Validity; Trauma
2.  Depression and resilience in women with HIV and early life stress: does trauma play a mediating role? A cross-sectional study 
BMJ Open  2014;4(2):e004200.
The present study sought to assess the relationship between depressive symptomatology and resilience among women infected with HIV and to investigate whether trauma exposure (childhood trauma, other discrete lifetime traumatic events) or the presence of post-traumatic stress symptomatology mediated this relationship.
Cross-sectional study.
Western Cape, South Africa.
A convenience sample of 95 women infected with HIV in peri-urban communities in the Western Cape, South Africa. All women had exposure to moderate-to-severe childhood trauma as determined by the Childhood Trauma Questionnaire.
Primary and secondary outcome measures
We examined the relationship between depressive symptomatology and resilience (the Connor-Davidson Resilience Scale) and investigated whether trauma exposure or the presence of post-traumatic stress symptomatology mediated this relationship through the Sobel test for mediation and PLS path analysis.
There was a significant negative correlation between depressive symptomatology and resilience (p=<0.01). PLS path analysis revealed a significant direct effect between depression and resilience. On the Sobel test for mediation, distal (childhood trauma) and proximal traumatic events did not significantly mediate this association (p=> 0.05). However, post-traumatic stress symptomatology significantly mediated the relationship between depression and resilience in trauma-exposed women living with HIV.
In the present study, higher levels of resilience were associated with lower levels of self-reported depression. Although causal inferences are not possible, this suggests that in this sample, resilience may act as protective factor against the development of clinical depression. The results also indicate that post-traumatic stress symptoms (PTSS), which are highly prevalent in HIV-infected and trauma exposed individuals and often comorbid with depression, may further explain and account for this relationship. Further investigation is required to determine whether early identification and treatment of PTSS in this population may ameliorate the onset and persistence of major depression.
PMCID: PMC3939658  PMID: 24566532
3.  Moderating effects of resilience on depression in individuals with a history of childhood abuse or trauma exposure 
Journal of affective disorders  2010;126(3):411-414.
Influences of resilience on the presence and severity of depression following trauma exposure are largely unknown. Hence, we examined effects of resilience on depressive symptom severity in individuals with past childhood abuse and/or other trauma exposure.
In this cross-sectional study of 792 adults, resilience was measured with the Connor–Davidson Resilience Scale, depression with the Beck Depression Inventory (BDI), childhood abuse with the Childhood Trauma Questionnaire, and other traumas with the Trauma Events Inventory.
Multiple linear regression modeling with depression severity (BDI score) as the outcome yielded 4 factors: childhood abuse (β=2.5, p<0.0001), other trauma (β=3.5, p<0.0001), resilience (β=−0.5, p<0.0001), and other trauma×resilience interaction term (β=−0.1, p=0.0021), all of which were significantly associated with depression severity, even after adjusting for age, sex, race, education, employment, income, marital status, and family psychiatric history. Childhood abuse and trauma exposure contributed to depressive symptom severity while resilience mitigated it.
Resilience moderates depressive symptom severity in individuals exposed to childhood abuse or other traumas both as a main effect and an interaction with trauma exposure. Resilience may be amenable to external manipulation and could present a potential focus for treatments and interventions.
PMCID: PMC3606050  PMID: 20488545
Resilience; Trauma; Childhood abuse; Depression; Moderating effects
4.  Measurement and Predictors of Resilience Among Community-Dwelling Older Women 
Journal of psychiatric research  2008;43(2):148-154.
Resilience, the ability to adapt positively to adversity, may be an important factor in successful aging. However, the assessment and correlates of resilience in elderly individuals have not received adequate attention.
A total of 1,395 community-dwelling women over age 60 who were participants at the San Diego Clinical Center of the Women’s Health Initiative completed the Connor-Davidson Resilience Scale (CD-RISC), along with other scales pertinent to successful cognitive aging. Internal consistency and predictors of the CD-RISC were examined, as well as the consistency of its factor structure with published reports.
The mean age of the cohort was 73 (7.2) years and 14% were Hispanic, 76% were non-Hispanic white, and nearly all had completed a high school education (98%). The mean total score on the CD-RISC was 75.7 (SD=13.0). This scale showed high internal consistency (Cronbach’s alpha=0.92). Exploratory factor analysis yielded four factors (somewhat different from those previously reported among younger adults) that reflected items involving: 1) personal control and goal orientation, 2) adaptation and tolerance for negative affect, 3) leadership and trust in instincts, and 4) spiritual coping. The strongest predictors of CD-RISC scores in this study were higher emotional well-being, optimism, self-rated successful aging, social engagement, and fewer cognitive complaints.
Our study suggests that the CD-RISC is an internally consistent scale for assessing resilience among older women, and that greater resilience as assessed by the CD-RISC related positively to key components of successful aging.
PMCID: PMC2613196  PMID: 18455190
Resilience; adaptation; elderly; successful aging; cognition; optimism
5.  The Effect of Resilience on Posttraumatic Stress Disorder in Trauma-Exposed Inner-City Primary Care Patients 
Posttraumatic stress disorder (PTSD) has previously been associated with increased risk for a variety of chronic medical conditions and it is often underdiagnosed in minority civilian populations. The current study examined the effects of resilience on the likelihood of having a diagnosis of PTSD in an inner-city sample of primary care patients (n = 767). We measured resilience with the Connor-Davidson Resilience Scale, trauma with the Childhood Trauma Questionnaire and Trauma Events Inventory, and assessed for PTSD with the modified PTSD symptom scale. Multiple logistic regression model with presence/absence of PTSD as the outcome yielded 3 significant factors: childhood abuse, nonchild abuse trauma, and resilience. One type of childhood abuse in moderate to severe range (OR, 2.01; p = .0001), 2 or more types of childhood abuse in moderate to severe range (OR, 4.00; p ≤ .0001), and 2 or more types of nonchildhood abuse trauma exposure (OR, 3.33; p ≤ .0001), were significantly associated with an increased likelihood of PTSD, while resilience was robustly and significantly associated with a decreased likelihood of PTSD (OR, 0.93; p ≤ .0001). By understanding the role of resilience in recovery from adverse experiences, improved treatment and interventional methods may be developed. Furthermore, these results suggest a role for assessing resilience in highly traumatized primary care populations as a way to better characterize risk for PTSD and direct screening/psychiatric referral efforts.
PMCID: PMC3691279  PMID: 21999030
psychiatry; urban population
6.  An abbreviated version of the Connor-Davidson Resilience Scale (CD-RISC), the CD-RISC2: Psychometric properties and applications in psychopharmacological trials 
Psychiatry research  2007;152(2-3):293-297.
Resilience may be an important component of prevention of neuropsychiatric disease. Resilience has proven to be quantifiable by scales such as the Connor-Davidson Resilience Scale (CD-RISC). Here, we introduce a 2-item version of this scale, the CD-RISC2. We hypothesize that this shortened version of the scale has internal consistency, test-retest reliability, convergent validity, and divergent validity as well as significant correlation with the full scale. Additionally, we hypothesize that the CD-RISC2 can be used to assess pharmacological modification of resilience. We test these hypotheses by utilizing data from treatment trials of post-traumatic stress disorder, major depression, and generalized anxiety disorder with setraline, mirtazapine, fluoxetine, paroxetine, venlafaxine XR, and kava as well as data from the general population, psychiatric outpatients, and family medicine clinic patients.
PMCID: PMC2041449  PMID: 17459488
Anxiety; treatment; hardiness
7.  Resilience as a Possible Predictor for Psychological Distress in Chronic Spinal Cord Injured Patients Living in the Community 
Annals of Rehabilitation Medicine  2012;36(6):815-820.
To investigate whether higher resilience level predicts low levels of psychological distress in chronic SCI patients living in the community.
Thirty seven patients (mean age 41.5±10.9, male : female=28 : 9) with chronic spinal cord injury (duration 8.35±7.0 years) living in the community are included, who were hospitalized for annual checkups from November, 2010 to May, 2011. First, their spinal cord injury level, completeness and complications were evaluated. The patients completed questionnaires about their educational status, religion, employment status, marital status, medical and psychological history and also the following questionnaires: Hospital Anxiety and Depression Scale (HADS), Connor-Davidson Resilience Scale (CD-RISC), Alcohol Use Disorders Identification Test-alcohol consumption questions (AUDIT-C) and Health-related quality of life (EQ-5D). The patients were divided into two subgroups: patients with HADS ≥13 are classified as high psychological distress group and others as low psychological distress group. We compared the two groups to find statistically significant differences among the variables.
CD-RISC, EQ-5D and employment status are significantly different between two groups (p<0.05). In a forward stepwise regression, we found that EQ-5D had a greater contribution than CD-RISC to the psychological distress level.
In addition to health-related quality of life, resilience can be suggested as a possible predictor of psychological distress in chronic SCI patients.
PMCID: PMC3546184  PMID: 23342314
Resilience; Predictor; Spinal cord injuries
8.  Traumatic Severity and Trait Resilience as Predictors of Posttraumatic Stress Disorder and Depressive Symptoms among Adolescent Survivors of the Wenchuan Earthquake 
PLoS ONE  2014;9(2):e89401.
To examine the associations between trauma severity, trait resilience, and posttraumatic stress disorder (PTSD) and depressive symptoms among adolescent survivors of the Wenchuan earthquake, China.
788 participants were randomly selected from secondary schools in the counties of Wenchuan and Maoxian, the two areas most severely affected by the earthquake. Participants completed four main questionnaires including the Child PTSD Symptom Scale, the Center for Epidemiologic Studies Depression Scale for Children, the Connor and Davidson’s Resilience Scale, and the Severity of Exposure to Earthquake Scale.
After adjusting for the effect of age and gender, four aspects of trauma severity (i.e., direct exposure, indirect exposure, worry about others, and house damage) were positively associated with the severity of PTSD and depressive symptoms, whereas trait resilience was negatively associated with PTSD and depressive symptoms and moderated the relationship between subjective experience (i.e., worry about others) and PTSD and depressive symptoms.
Several aspects (i.e., direct exposure, indirect exposure, worry about others, and house damage) of earthquake experiences may be important risk factors for the development and maintenance of PTSD and depression. Additionally, trait resilience exhibits the beneficial impact on PTSD and depressive symptoms and buffers the effect of subjective experience (i.e., worry about others) on PTSD and depressive symptoms.
PMCID: PMC3935868  PMID: 24586751
9.  Reliability and validity of the Spanish version of the 10-item Connor-Davidson Resilience Scale (10-item CD-RISC) in young adults 
The 10-item Connor-Davidson Resilience Scale (10-item CD-RISC) is an instrument for measuring resilience that has shown good psychometric properties in its original version in English. The aim of this study was to evaluate the validity and reliability of the Spanish version of the 10-item CD-RISC in young adults and to verify whether it is structured in a single dimension as in the original English version.
Cross-sectional observational study including 681 university students ranging in age from 18 to 30 years. The number of latent factors in the 10 items of the scale was analyzed by exploratory factor analysis. Confirmatory factor analysis was used to verify whether a single factor underlies the 10 items of the scale as in the original version in English. The convergent validity was analyzed by testing whether the mean of the scores of the mental component of SF-12 (MCS) and the quality of sleep as measured with the Pittsburgh Sleep Index (PSQI) were higher in subjects with better levels of resilience. The internal consistency of the 10-item CD-RISC was estimated using the Cronbach α test and test-retest reliability was estimated with the intraclass correlation coefficient.
The Cronbach α coefficient was 0.85 and the test-retest intraclass correlation coefficient was 0.71. The mean MCS score and the level of quality of sleep in both men and women were significantly worse in subjects with lower resilience scores.
The Spanish version of the 10-item CD-RISC showed good psychometric properties in young adults and thus can be used as a reliable and valid instrument for measuring resilience. Our study confirmed that a single factor underlies the resilience construct, as was the case of the original scale in English.
PMCID: PMC3173284  PMID: 21819555
Resilience; 10-item CD-RISC; Young adults; Reliability; Validity; Questionnaire
10.  Stress Management and Resilience Training Among Department of Medicine Faculty: A Pilot Randomized Clinical Trial 
Physician distress is common and related to numerous factors involving physicians’ personal and professional lives. The present study was designed to assess the effect of a Stress Management and Resiliency Training (SMART) program for increasing resiliency and quality of life, and decreasing stress and anxiety among Department of Medicine (DOM) physicians at a tertiary care medical center.
Forty DOM physicians were randomized in a wait-list controlled clinical trial to either the SMART intervention or a wait-list control group for 8 weeks. The intervention involved a single 90 min one-on-one training in the SMART program. Primary outcome measures assessed at baseline and week 8 included the Connor Davidson Resilience Scale (CDRS), Perceived Stress Scale (PSS), Smith Anxiety Scale (SAS) and Linear Analog Self Assessment Scale (LASA).
Thirty-two physicians completed the study. A statistically significant improvement in resiliency, perceived stress, anxiety, and overall quality of life at 8 weeks was observed in the study arm compared to the wait-list control arm: CDRS: mean ± SD change from baseline +9.8 ± 9.6 vs. -0.8 ± 8.2, t(30) = 3.18, p = 0.003; PSS: -5.4 ± 8.1 vs. +2.2 ± 6.1, t(30) = -2.76, p = 0.010; SAS: -11.8 ± 12.3 vs.+ 2.9 ± 8.9, t(30) = -3.62, p = 0.001; and LASA: +0.4 ± 1.4 vs. -0.6 ± 1.0, t(30) = 2.29, p = 0.029.
A brief training to enhance resilience and decrease stress among physicians using the SMART program was feasible. Further, the intervention provided statistically significant improvement in resilience, stress, anxiety, and overall quality of life. In the future, larger clinical trials with longer follow-up and possibly wider dissemination of this intervention are warranted.
PMCID: PMC3138987  PMID: 21279454
stress; resilience; wellness; physicians; burnout
11.  Resilience: Building immunity in psychiatry 
Indian Journal of Psychiatry  2013;55(3):224-234.
The challenges in our personal, professional, financial, and emotional world are on rise, more so in developing countries and people will be longing for mental wellness for achieving complete health in their life. Resilience stands for one's capacity to recover from extremes of trauma and stress. Resilience in a person reflects a dynamic union of factors that encourages positive adaptation despite exposure to adverse life experiences. One needs to have a three-dimensional construct for understanding resilience as a state (what is it and how does one identify it?), a condition (what can be done about it?), and a practice (how does one get there?). Evaluating the level of resilience requires the measurement of internal (personal) and external (environmental) factors, taking into account that family and social environment variables of resilience play very important roles in an individual's resilience. Protection factors seem to be more important in the development of resilience than risk factors. Resilience is a process that lasts a lifetime, with periods of acquisition and maintenance, and reduction and loss for assessment. Overall, currently available data on resilience suggest the presence of a neurobiological substrate, based largely on genetics, which correlates with personality traits, some of which are configured via social learning. The major questions about resilience revolve around properly defining the concept, identifying the factors involved in its development and recognizing whether it is actually possible to immunize mental health against adversities. In the clinical field, it may be possible to identify predisposing factors or risk factors for psychopathologies and to develop new intervention strategies, both preventive and therapeutic, based on the concept of resilience. The preferred environments for application of resilience are health, education, and social policy and the right approach in integrating; it can be developed only with more research and analysis with focus on resilience. Be it patient or family member or caregiver, advocating resilience will empower psychiatrists in India.
PMCID: PMC3777343  PMID: 24082242
Clinical application; environment; neurobiology; protective factors; resilience; risk factors
12.  The presence of resilience is associated with a healthier psychological profile in ICU nurses: Results of a national survey 
ICU nurses are repeatedly exposed to work related stresses resulting in the development of psychological disorders including posttraumatic stress disorder and burnout syndrome. Resilience is a learnable multidimensional characteristic enabling one to thrive in the face of adversity. In a national survey, we sought to determine whether resilience was associated with healthier psychological profiles in intensive care unit nurses.
Surveys were mailed to 3500 randomly selected ICU nurses across the United States and included: demographic questions, the Posttraumatic Diagnostic Scale, Hospital Anxiety and Depression Scale, Maslach Burnout Inventory and the Connor-Davidson Resilience Scale.
Measurements and Main Results
Overall, 1239 of the mailed surveys were returned for a response rate of 35%, and complete data was available on a total of 744 nurses. Twenty-two percent of the intensive care unit nurses were categorized as being highly resilient. The presence of high resilience in these nurses was significantly associated with a lower prevalence of posttraumatic stress disorder, symptoms of anxiety or depression, and burnout syndrome (<0.001 for all comparisons). In independent multivariable analyses adjusting for five potential confounding variables, the presence of resilience was independently associated with a lower prevalence of posttraumatic stress disorder (p < 0.001), and a lower prevalence of burnout syndrome (p < 0.001).
The presence of psychological resilience was independently associated with a lower prevalence of posttraumatic stress disorder and burnout syndrome in intensive care unit nurses. Future research is needed to better understand coping mechanisms employed by highly resilient nurses and how they maintain a healthier psychological profile.
PMCID: PMC3276701  PMID: 21974793
Resilience; posttraumatic stress disorder; burnout syndrome; ICU nurses
13.  A methodological review of resilience measurement scales 
The evaluation of interventions and policies designed to promote resilience, and research to understand the determinants and associations, require reliable and valid measures to ensure data quality. This paper systematically reviews the psychometric rigour of resilience measurement scales developed for use in general and clinical populations.
Eight electronic abstract databases and the internet were searched and reference lists of all identified papers were hand searched. The focus was to identify peer reviewed journal articles where resilience was a key focus and/or is assessed. Two authors independently extracted data and performed a quality assessment of the scale psychometric properties.
Nineteen resilience measures were reviewed; four of these were refinements of the original measure. All the measures had some missing information regarding the psychometric properties. Overall, the Connor-Davidson Resilience Scale, the Resilience Scale for Adults and the Brief Resilience Scale received the best psychometric ratings. The conceptual and theoretical adequacy of a number of the scales was questionable.
We found no current 'gold standard' amongst 15 measures of resilience. A number of the scales are in the early stages of development, and all require further validation work. Given increasing interest in resilience from major international funders, key policy makers and practice, researchers are urged to report relevant validation statistics when using the measures.
PMCID: PMC3042897  PMID: 21294858
14.  Validity and reliability of the Spanish version of the 10-item CD-RISC in patients with fibromyalgia 
No resilience scale has been validated in Spanish patients with fibromyalgia. The aim of this study was to evaluate the validity and reliability of the 10-item CD-RISC in a sample of Spanish patients with fibromyalgia.
Design: Observational prospective multicenter study. Sample: Patients with diagnoses of fibromyalgia recruited from primary care settings (N = 208). Instruments: In addition to sociodemographic data, the following questionnaires were administered: Pain Visual Analogue Scale (PVAS), the 10-item Connor-Davidson Resilience scale (10-item CD-RISC), the Fibromyalgia Impact Questionnaire (FIQ), the Hospital Anxiety and Depression Scale (HADS), the Pain Catastrophizing Scale (PCS), the Chronic Pain Acceptance Questionnaire (CPAQ), and the Mindful Attention Awareness Scale (MAAS).
Regarding construct validity, the factor solution in the Principal Component Analysis (PCA) was considered adequate, so the KMO test had a value of 0.91, and the Barlett’s test of sphericity was significant (χ2 = 852.8; gl = 45; p < 0.001). Only one factor showed an eigenvalue greater than 1, and it explained 50.4% of the variance. PCA and Confirmatory Factor Analysis (CFA) results did not show significant differences between groups. The 10-item CD-RISC scale demonstrated good internal consistency (Cronbach’s alpha = 0.88) and test-retest reliability (r = 0.89 for a six-week interval). The 10-item CD-RISC score was significantly correlated with all of the other psychometric instruments in the expected direction, except for the PVAS (−0.115; p = 0.113).
Our study confirms that the Spanish version of the 10-item CD-RISC shows, in patients with fibromyalgia, acceptable psychometric properties, with a high level of reliability and validity.
PMCID: PMC3922630  PMID: 24484847
Resilience; Fibromyalgia; Validation; 10-item CD-RISC
15.  All in for mental health: a pilot study of group therapy for people experiencing anxiety and/or depression and a significant other of their choice 
Background A need to provide treatment for people with anxiety and/or depression, and to provide preventive strategies for individuals who love them has been identified. In response, an innovative group therapy programme for people with anxiety and/or depression and a significant other of their choice was developed and implemented.
Methods Mixed methods were employed. Five ‘significant other’ groups were held between May 2005 and June 2006. All group participants were requested to complete the Depression Anxiety Stress Scale (DASS), World Health Organization Quality of Life Assessment (WHOQol) and Connor–Davidson Resilience Scale (CD-RISC), pre- and post-therapy, and three months after their last therapy session. In addition, participants who attended groups between July and September 2005 were invited to provide feedback about the group therapy in an individual semi-structured interview.
Results Pilot results indicate positive responses from clients, related to facilitation of knowledge and understanding and skills development. For people referred to the group significant improvements were found in the DASS scores, resilience, psychological health and living environment.
Limitations Due to the small sample size, and lack of follow-up data and control group, the findings need to be considered with caution and indicate the necessity to collect further data to provide conclusive findings.
Conclusions Overall, the outcome of the ‘significant other’ pilot programme was useful, in that it facilitated a number of positive outcomes for participants. Areas for further research have been identified including strategies to improve social relationships, the de-identification with the sick/supporter role, and testing this model with diverse populations and clinical groups.
PMCID: PMC2777547  PMID: 22477845
anxiety and/or depression; family; group therapy
16.  “I know it when I see it.” The complexities of measuring resilience among parents of children with cancer 
Promoting parent resilience may provide an opportunity to improve family-level survivorship after pediatric cancer; however, measuring resilience is challenging.
The “Understanding Resilience in Parents of Children with Cancer” was a cross-sectional, mixed-methods study of bereaved and non-bereaved parents. Surveys included the Connor-Davidson Resilience scale, the Kessler-6 psychological distress scale, the Post-Traumatic Growth Inventory, and an open-ended question regarding the on-going impact of cancer. We conducted content analyses of open-ended responses and categorized our impressions as “resilient,” “not resilient,” or “unable to determine.” “Resilience” was determined based on evidence of psychological growth, lack of distress, and parent-reported meaning/purpose. We compared consensus-impressions with instrument scores to examine alignment. Analyses were stratified by bereavement status.
Eighty-four (88%) non-bereaved, and 21 (88%) bereaved parents provided written responses. Among non-bereaved, 53 (63%) were considered resilient, 15 (18%) were not. Among bereaved, 11 (52%) were deemed resilient, 5 (24%) were not. All others suggested a mixed or incomplete picture. Rater-determined “resilient” parents tended to have higher personal resources and lower psychological distress (p=<0.001–0.01). Non-bereaved “resilient” parents also had higher post-traumatic growth (p=0.02). Person-level analyses demonstrated that only 50–62% of parents had all 3 instrument scores aligned with our impressions of resilience.
Despite multiple theories, measuring resilience is challenging. Our clinical impressions of resilience were aligned in 100% of cases; however, instruments measuring potential markers of resilience were aligned in approximately half. Promoting resilience therefore requires understanding of multiple factors, including person-level perspectives, individual resources, processes of adaptation and emotional well-being.
PMCID: PMC4264630  PMID: 24756554
Cancer; Oncology; Pediatrics; Parents; Resilience; Psychosocial Outcomes
17.  The posttraumatic stress disorder project in Brazil: neuropsychological, structural and molecular neuroimaging studies in victims of urban violence 
BMC Psychiatry  2009;9:30.
Life trauma is highly prevalent in the general population and posttraumatic stress disorder is among the most prevalent psychiatric consequences of trauma exposure. Brazil has a unique environment to conduct translational research about psychological trauma and posttraumatic stress disorder, since urban violence became a Brazilian phenomenon, being particularly related to the rapid population growth of its cities. This research involves three case-control studies: a neuropsychological, a structural neuroimaging and a molecular neuroimaging study, each focusing on different objectives but providing complementary information. First, it aims to examine cognitive functioning of PTSD subjects and its relationships with symptomatology. The second objective is to evaluate neurostructural integrity of orbitofrontal cortex and hippocampus in PTSD subjects. The third aim is to evaluate if patients with PTSD have decreased dopamine transporter density in the basal ganglia as compared to resilient controls subjects. This paper shows the research rationale and design for these three case-control studies.
Methods and design
Cases and controls will be identified through an epidemiologic survey conducted in the city of São Paulo. Subjects exposed to traumatic life experiences resulting in posttraumatic stress disorder (cases) will be compared to resilient victims of traumatic life experiences without PTSD (controls) aiming to identify biological variables that might protect or predispose to PTSD. In the neuropsychological case-control study, 100 patients with PTSD, will be compared with 100 victims of trauma without posttraumatic stress disorder, age- and sex-matched controls. Similarly, 50 cases and 50 controls will be enrolled for the structural study and 25 cases and 25 controls in the functional neuroimaging study. All individuals from the three studies will complete psychometrics and a structured clinical interview (the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale, Beck Anxiety Inventory, Beck Depression Inventory, Global Assessment of Function, The Social Adjustment Scale, Medical Outcomes Study 36-Item Short-Form Health Survey, Early Trauma Inventory, Clinical global Impressions, and Peritraumatic Dissociative Experiences Questionnaire). A broad neuropsychological battery will be administered for all participants of the neuropsychological study. Magnetic resonance scans will be performed to acquire structural neuroimaging data. Single photon emission computerized tomography with [(99m)Tc]-TRODAT-1 brain scans will be performed to evaluate dopamine transporters.
This study protocol will be informative for researchers and clinicians interested in considering, designing and/or conducting translational research in the field of trauma and posttraumatic stress disorder.
PMCID: PMC2702374  PMID: 19480721
18.  Reassessment of the Psychometric Characteristics and Factor Structure of the ‘Perceived Stress Questionnaire’ (PSQ): Analysis in a Sample of Dental Students 
PLoS ONE  2014;9(1):e87071.
The training to become a dentist can create psychological distress. The present study evaluates the structure of the ‘Perceived Stress Questionnaire’ (PSQ), its internal consistency model and interrelatedness with burnout, anxiety, depression and resilience among dental students.
The study employed a cross-sectional design. A sample of Spanish dental students (n = 314) completed the PSQ, the ‘Goldberg Anxiety and Depression Scale’ (GADS), ‘Connor-Davidson Resilience Scale’ (10-item CD-RISC) and ‘Maslach Burnout Inventory-Student Survey’ (MBI-SS). The structure was estimated using Parallel Analysis from polychoric correlations. Unweighted Least Squares was the method for factor extraction, using the Item Response Theory to evaluate the discriminative power of items. Internal consistency was assessed by squaring the correlation between the latent true variable and the observed variable. The relationships between the PSQ and the other constructs were analysed using Spearman’s coefficient.
The results showed a PSQ structure through two sub-factors (‘frustration’ and ‘tenseness’) with regard to one general factor (‘perceived stress’). Items that did not satisfy discriminative capacity were rejected. The model fit were acceptable (GFI = 0.98; RSMR = 0.06; AGFI = 0.98; NFI = 0.98; RFI = 0.98). All the factors showed adequate internal consistency as measured by the congeneric model (≥0.91). High and significant associations were observed between perceived stress and burnout, anxiety, depression and resilience.
The PSQ showed a hierarchical bi-factor structure among Spanish dental students. Using the questionnaire as a uni-dimensional scale may be useful in perceived stress level discrimination, while the sub-factors could help us to refine perceived stress analysis and improve therapeutic processes.
PMCID: PMC3900726  PMID: 24466330
19.  Emotional Regulation and Adjustment to Childhood Cancer: Role of the Biological, Psychological and Social Regulators on Pediatric Oncology Adjustment 
Children with cancer should deal with difficult situations such asundergoing multimodal treatment. Emotion Regulation Mechanisms (ERM) could be more effective for childhood cancer adaptation. The main purpose of this study was examination a number of the biological, psychological and social emotion regulators on adjustment to pediatric oncology.
In this study, 98 children (39 girls and 59 boys) have participated that diagnosed as Acute Lymphoblastic Leukemia (ALL) cases along with their mothers. The participants were between 8 to 12 years old. Salivary cortisol, cognitive emotion regulation, children's level of inhibition, maternal positivity and Beck Depression Inventory have been applied for evaluation of Emotion Regulation (ER) while Cancer-Specific Stress and Coping, Connor-Davidson Resilience Scale, anxiety-depression scales and vitality test have all used for assessing the Emotional Adjustment (EA).
Using the canonical correlation has been showing significant relation between predictors of ER and EA. Cortisol level and mother's depression have played the most important role in above correlation.
Variation of cortisol level has identified by its various effects on the mother's behavioral system depression, cognitive strategies and emotional inhibition; would determine the rate of coping with cancer, resiliency and vitality.
PMCID: PMC4142920  PMID: 25250113
Child; Malignancy; Emotions; Adaptation
20.  Psychosocial facets of resilience: implications for preventing posttrauma psychopathology, treating trauma survivors, and enhancing community resilience 
European Journal of Psychotraumatology  2014;5:10.3402/ejpt.v5.23970.
There is a range of potential responses to stress and trauma. Whereas, on one extreme, some respond to stress and trauma by developing psychiatric disorders (e.g., posttraumatic stress disorder, PTSD), on the other extreme are the ones who exhibit resilience. Resilience is broadly defined as adaptive characteristics of an individual to cope with and recover from adversity.
Understanding of the factors that promote resilience is warranted and can be obtained by interviewing and learning from particularly resilient individuals as well as empirical research. In this paper, we discuss a constellation of factors comprising cognitive, behavioral, and existential elements that have been identified as contributing to resilience in response to stress or trauma.
The psychosocial factors associated with resilience include optimism, cognitive flexibility, active coping skills, maintaining a supportive social network, attending to one's physical well-being, and embracing a personal moral compass.
These factors can be cultivated even before exposure to traumatic events, or they can be targeted in interventions for individuals recovering from trauma exposure. Currently available interventions for PTSD could be expanded to further address these psychosocial factors in an effort to promote resilience. The cognitive, behavioral, and existential components of psychosocial factors that promote individual resilience can also inform efforts to promote resilience to disaster at the community level.
PMCID: PMC4185137  PMID: 25317258
Resilience; trauma; psychosocial; factors
21.  Mental health and resiliency following 44 months of terrorism: a survey of an Israeli national representative sample 
BMC Medicine  2006;4:21.
Israeli citizens have been exposed to intense and ongoing terrorism since September 2000. We previously studied the mental health impact of terrorism on the Israeli population (Bleich et al., 2002), however the long-term impact of ongoing terrorism has not yet been examined. The present study evaluated the psychological sequelae of 44 months of terrorism in Israel, and sought to identify factors that may contribute to vulnerability and resilience.
This was a telephone survey using strata sampling of 828 households, which reached a representative sample of 702 adult Israeli residents (84.8% contact rate). In total, 501 people (60.5%) agreed to participate. The methodology was similar to that of our previous study. Exposure to terrorism and other traumatic events, number of traumatic stress-related symptoms (TSRS), percentage of respondents with symptom criteria for post-traumatic stress disorder (PTSD), traumatic stress (TS) resiliency and feelings of depression, anxiety, optimism, sense of safety, and help-seeking were the main outcome measures.
In total, 56 participants (11.2%) were directly exposed to a terrorist incident, and 101 (20.2%) had family members or friends exposed. Respondents reported a mean ± SD of 5.0 ± 4.5 TSRS; 45 (9%) met symptom criteria for PTSD; and 72 (14.4%) were TS-resilient. There were 147 participants (29.5%) who felt depressed, 50 (10.4%) felt anxious, and almost half (235; 47%) felt life-threatening danger; 48 (9.7%) felt the need for professional help. Women and people of Arab ethnicity had more TSRS, more PTSD, and less TS resiliency. Injury following a life-threatening experience, a major stressful life event, and a major loss of income were associated with PTSD. Immigrant status, lower education, low sense of safety, low sense of social support, high societal distress, and injury following life-threatening experiences were associated with TSRS. TSRS did not increase with exposure severity. This study revealed less depression and functional impairment, similar rates of PTSD, increased help-seeking and poorer TSRS and TS resiliency than our initial study, 2 years previously.
The response of people in Israel to 4 years of terrorism is heterogeneous. Vulnerability factors change over time; Arab ethnicity, immigrant status and less education, not found to be risk factors in our previous study, were found in the present study to contribute to trauma-related distress. Prior experience of highly stressful events increases vulnerability to adverse psychological effects of terror.
PMCID: PMC1560155  PMID: 16934160
22.  PTSD onset and course following the World Trade Center disaster: findings and implications for future research 
We sought to identify common risk factors associated with posttraumatic stress disorder (PTSD) onset and course, including delayed, persistent, and remitted PTSD following a major traumatic exposure.
Based on a prospective study of New York City adults following the World Trade Center disaster (WTCD), we conducted baseline interviews with 2,368 persons one year after this event and then at follow-up 1 year later to evaluate changes in current PTSD status based on DSM-IV criteria.
Baseline analysis suggested that current PTSD, defined as present if this occurred in the past 12 months, was associated with females, younger adults, those with lower self-esteem, lower social support, higher WTCD exposure, more lifetime traumatic events, and those with a history of pre-WTCD depression. At follow-up, current PTSD was associated with Latinos, non-native born persons, those with lower self-esteem, more negative life events, more lifetime traumatic events, and those with mixed handedness. Classifying respondents at follow-up into resilient (no PTSD time 1 or 2), remitted (PTSD time 1, not 2), delayed (no PTSD time 1, but PTSD time 2), and persistent (PTSD both time 1 and 2) PTSD, revealed the following: compared to resilient cases, remitted ones were more likely to be female, have more negative life events, have greater lifetime traumatic events, and have pre-WTCD depression. Delayed cases were more likely to be Latino, be non-native born, have lower self-esteem, have more negative life events, have greater lifetime traumas, and have mixed handedness. Persistent cases had a similar profile as delayed, but were the only cases associated with greater WTCD exposures. They were also likely to have had a pre-WTCD depression diagnosis. Examination of WTCD-related PTSD at follow-up, more specifically, revealed a similar risk profile, except that handedness was no longer significant and WTCD exposure was now significant for both remitted and persistent cases.
PTSD onset and course is complex and appears to be related to trauma exposure, individual predispositions, and external factors not directly related to the original traumatic event. This diagnostic classification may benefit from additional conceptualization and research as this relates to changes in PTSD status over time.
PMCID: PMC2762428  PMID: 19277439
Posttraumatic stress disorder; Delayed-onset; Predisposition; Resiliency; Stressful events
23.  Lifetime Trauma Exposure and Prospective Cardiovascular Events and All-cause Mortality: Findings from the Heart and Soul Study 
Psychosomatic medicine  2013;75(9):849-855.
Little is known about the effect of cumulative psychological trauma on health outcomes in patients with cardiovascular disease. The objective of this study was to prospectively examine the association between lifetime trauma exposure and recurrent cardiovascular events or all-cause mortality in patients with existing cardiovascular disease.
1,021 men and women with cardiovascular disease were recruited in 2000–2002 and followed annually. Trauma history and psychiatric comorbidities were assessed at baseline using the Computerized Diagnostic Interview Schedule for DSM-IV. Health behaviors were assessed using standardized questionnaires. Outcome data was collected annually, and all medical records were reviewed by two independent, blinded physician adjudicators. We used Cox proportional hazards models to evaluate the association between lifetime trauma exposure and the composite outcome of cardiovascular events and all-cause mortality.
During an average of 7.5 years follow-up, there were 503 cardiovascular events and deaths. Compared with the 251 participants in the lowest trauma exposure quartile, the 256 participants in the highest exposure quartile had a 38% greater risk of adverse outcomes (HR 1.38, 95% CI 1.06–1.81), adjusted for age, sex, race, income, education, depression, posttraumatic stress disorder, generalized anxiety disorder, smoking, physical inactivity, and illicit drug abuse.
Cumulative exposure to psychological trauma was associated with an increased risk of recurrent cardiovascular events and mortality, independent of psychiatric comorbidities and health behaviors. These data add to a growing literature showing enduring effects of repeated trauma exposure on health that are independent of trauma-related psychiatric disorders such as depression and posttraumatic stress disorder.
PMCID: PMC4014357  PMID: 24149074
Cardiovascular disease; psychological trauma; myocardial infarction; depression; post-traumatic stress disorder; cardiovascular mortality
24.  Hopefulness predicts resilience after hereditary colorectal cancer genetic testing: a prospective outcome trajectories study 
BMC Cancer  2010;10:279.
Background -
Genetic testing for hereditary colorectal cancer (HCRC) had significant psychological consequences for test recipients. This prospective longitudinal study investigated the factors that predict psychological resilience in adults undergoing genetic testing for HCRC.
Methods -
A longitudinal study was carried out from April 2003 to August 2006 on Hong Kong Chinese HCRC family members who were recruited and offered genetic testing by the Hereditary Gastrointestinal Cancer Registry to determine psychological outcomes after genetic testing. Self-completed questionnaires were administered immediately before (pre-disclosure baseline) and 2 weeks, 4 months and 1 year after result disclosure. Using validated psychological inventories, the cognitive style of hope was measured at baseline, and the psychological distress of depression and anxiety was measured at all time points.
Results -
Of the 76 participating subjects, 71 individuals (43 men and 28 women; mean age 38.9 ± 9.2 years) from nine FAP and 24 HNPCC families completed the study, including 39 mutated gene carriers. Four patterns of outcome trajectories were created using established norms for the specified outcome measures of depression and anxiety. These included chronic dysfunction (13% and 8.7%), recovery (0% and 4.3%), delayed dysfunction (13% and 15.9%) and resilience (76.8% and 66.7%). Two logistic regression analyses were conducted using hope at baseline to predict resilience, with depression and anxiety employed as outcome indicators. Because of the small number of participants, the chronic dysfunction and delayed dysfunction groups were combined into a non-resilient group for comparison with the resilient group in all subsequent analysis. Because of low frequencies, participants exhibiting a recovery trajectory (n = 3 for anxiety and n = 0 for depression) were excluded from further analysis. Both regression equations were significant. Baseline hope was a significant predictor of a resilience outcome trajectory for depression (B = -0.24, p < 0.01 for depression); and anxiety (B = -0.11, p = 0.05 for anxiety).
Conclusions -
The current findings suggest that hopefulness may predict resilience after HCRC genetic testing in Hong Kong Chinese. Interventions to increase the level of hope may be beneficial to the psychological adjustment of CRC genetic testing recipients.
PMCID: PMC2891641  PMID: 20537192
25.  Psychological Resilience and Neurocognitive Performance in a Traumatized Community Sample 
Depression and anxiety  2010;27(8):768-774.
Whether psychological resilience correlates with neurocognitive performance is largely unknown. Therefore, we assessed association between neurocognitive performance and resilience in individuals with a history of childhood abuse or trauma exposure.
In this cross-sectional study of 226 highly traumatized civilians, we assessed neurocognitive performance, history of childhood abuse and other trauma exposure, and current depressive and PTSD symptoms. Resilience was defined as having ≥ 1 trauma and no current depressive or PTSD symptoms; non-resilience as having ≥ 1 trauma and current moderate/severe depressive or PTSD symptoms.
The nonresilient group had a higher percentage of unemployment (p = 0.002) and previous suicide attempts (p <0.0001) than the resilient group. Both groups had comparable education and performance on verbal reasoning, nonverbal reasoning, and verbal memory. However, the resilient group performed better on nonverbal memory (p=0.016) with an effect size of 0.35. Additionally, more severe childhood abuse or other trauma exposure was significantly associated with non-resilience. Better nonverbal memory was significantly associated with resilience even after adjusting for severity of childhood abuse, other trauma exposure, sex, and race using multiple logistic regression (adjusted OR=1.2; p=0.017).
We examined resilience as absence of psychopathology despite trauma exposure in a highly traumatized, low socioeconomic, urban population. Resilience was significantly associated with better nonverbal memory, a measure of ability to code, store, and visually recognize concrete and abstract pictorial stimuli. Nonverbal memory may be a proxy for emotional learning, which is often dysregulated in stress-related psychopathology, and may contribute to our understanding of resilience.
PMCID: PMC2918658  PMID: 20186970
resilience; neurocognitive performance; trauma; childhood abuse; PTSD; depression; nonverbal memory

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