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Assessment of resilience in the aftermath of trauma

Assessment of Resilience in the Aftermath of Trauma
Kathryn M. Connor, M.D.
Resilience is a crucial component in determining the way in which individuals react to and deal with stress. A broad range of features is associated with resilience; these features relate to thestrengths and positive aspects of an individual’s mental state. In patients with posttraumatic stress dis-order, resilience can be used as a measure of treatment outcome, with improved resilience increasingthe likelihood of a favorable outcome. Resilience can be monitored using the Connor-Davidson Resil-ience Scale, and perceived vulnerability to the effects of stress can be monitored with the SheehanStress Vulnerability Scale. Both scales are well validated, self-rated, easy to use, and easily translat-able. Within a short period of time, nonspecialists can be taught to use these in the field.
(J Clin Psychiatry 2006;67[suppl 2]:46–49) osttraumatic stress disorder (PTSD) and associated being born into poverty, experiencing perinatal stress, symptoms account for considerable morbidity and and living in troubled family environments are risk factors mortality.1,2 Optimization of outcome in individuals af- for children developing serious learning or behavior prob- fected by trauma and PTSD is facilitated, in part, by the lems, resilient individuals who experience these factors application of tools to assess various components of the can still grow into competent, confident adults. Further- condition. In particular, it is crucial to establish the pres- more, Wagnild15(p42) has suggested that, regardless of an in- ence of and assess psychological resilience. Recent years dividual’s income, resilience may also be associated with have witnessed a growing interest in the concept of resil- “successful aging,” defined as “the enjoyment of health ience, and resilience is now recognized to be one of the and vigor of the mind, body, and spirit into middle age and most important factors in assessing both healthy and path- beyond.” Resilient older women have been found to be so- cially active, with mid-to-high scores for measures of life Resilience can be defined as a measure of stress-coping ability, and it describes personal qualities that allow in- Although disturbing life events increase the risk of dividuals and communities to grow and even thrive in depression, most people do not become depressed follow- the face of adversity.4–6 As such, resilience or “personality ing stressful experiences.16 Recent research suggests that hardiness”7 can be regarded as a measure of emotional greater resilience, as measured by the Connor-Davidson stamina.8 Several workers have suggested that the clinical Resilience Scale (CD-RISC)6 total score, as well as the significance of resilience may lie in its ability to function item of “having a sense of humor when things go badly,” as an index of overall mental health.9,10 is predictive of greater likelihood of recovery in patients In 1982, Kobasa et al.11 postulated that resilience is a with PTSD.17 Resilience has been shown to protect against crucial factor in determining how people react to and cope posttrauma breakdown and may help to alleviate an in- with stressful life events. This theory was later expanded dividual’s feelings of helplessness when faced with pres- by the suggestion that, when faced with such adverse sure or setback.18 Mental hardiness may help to protect experiences, resilient people tend to manifest adaptive against the development of chronic PTSD following com- behavior in the areas of morale, social functioning, and so- bat.19,20 In patients with PTSD treated with fluoxetine, the matic health.12,13 Beardslee13 proposed that resilient people drug may confer a resilience-building effect and produce are “survivors.” Indeed, Werner14 reported that, although The neurobiology of resilience has been reviewed by Charney,21 who has included patterns of neurochemical From the Department of Psychiatry and Behavioral response to acute stress, together with neural mechanisms Science, Duke University Medical Center, Durham, N.C. mediating fear conditioning and extinction, in an inte- Presented at the symposium “After the Tsunami: Mental Health Challenges to the Community for Today grative model of resilience and vulnerability. Charney de- and Tomorrow,” which was held February 2–3, 2005, in scribed 11 biochemical mediators of response to extreme Bangkok, Thailand, and supported by an educational grantfrom Pfizer Inc. stress that may be related to resilience or vulnerability, Corresponding author and reprints: Kathryn M. Connor, such as cortisol and dopamine. The author further noted M.D., Department of Psychiatry and Behavioral Science, DukeUniversity Medical Center, Durham, NC 27710 that several neurochemicals (dehydroepiandrosterone, neu- ropeptide Y, galanin, serotonin, benzodiazepine receptors, COPYRIGHT 2006 PHYSICIANS POSTGRADUATE PRESS, INC. COPYRIGHT 2006 PHYSICIANS POSTGRADUATE PRESS, INC.
they are more capable of adapting to change; they can use Table 1. Characteristics of Resiliencea
past successes to confront current challenges.23 Other qualities associated with resilience are patience and toler- ance of negative affect,3 as well as optimism and faith.6 These characteristics are substantiated by numerous studies. In the Kauai Longitudinal Study,14 individuals were followed for more than 30 years to assess the long- term developmental consequences of perinatal complica- tions and adverse rearing conditions in children. Resilient individuals were characterized by their personal compe- tence and determination, the supportive relationships they had formed, and their reliance on faith and prayer. Resilient youngsters all experienced unconditional acceptance by at least one person, with most establishing this close bond The beneficial character traits possessed by resilient in- dividuals may be influenced by neural mechanisms relating to reward and motivation (hedonia, optimism, and learned helpfulness), fear and responsiveness (effective behavior in Adapted with permission from Connor and Davidson.6 the presence of fear), and adaptive social behavior (altru-ism, bonding, and teamwork).21 Resilient individuals use positive emotions to recover testosterone, and estrogen) may ultimately promote resil- from negative emotional experiences.24 Evaluation of resil- ience, while the release of others (corticotropin-releasing ience should focus on strengths and positive attributes hormone and the locus ceruleus-norepinephrine system) rather than on weaknesses, thus encouraging the individual may tend to undermine resilience. There is also evidence that genetic factors may contribute to stress-related condi-tions such as PTSD.22 MEASURING RESILIENCE IN PATIENTS WITH PTSD This article will focus on resilience in patients with PTSD, with 3 main aims: (1) to describe the characteristics As observed by Ursano in 1987,25(p274) “The study of of resilience, (2) to examine the currently available meth- responses to trauma must include the study of resilience ods of assessing and quantifying resilience, and (3) to and health.” Although a number of clinical scales have briefly discuss the use of clinical scales to assess the effect been developed to assess resilience26,12 or aspects of resil- of various treatment strategies on resilience.
ience,7,27 none has gained wide acceptance or establishedprimacy.6 Furthermore, the Handbook of Psychiatric Mea- sures published in 2000 by the American Psychiatric Asso-ciation28 did not contain any measures of resilience. Limi- It is generally agreed that resilience develops over tations of the previously proposed scales left a clear need time.12 The concept of resilience comprises several differ- for well-validated, easy-to-use systems to be developed.
ent elements,6,17 and these are listed in Table 1.
The CD-RISC can be used to measure various aspects of The characteristics of resilient people have been stud- resilience in patients with PTSD and other allied states, as ied since the late 1970s, when Kobasa’s work7 showed that well as in healthy subjects.6 The Stress Vulnerability Scale people with greater hardiness also exhibit an internal locus (SVS) can be used to measure the degree of perceived dis- of control, a stronger sense of commitment to self, a sense tress following everyday stress or setbacks.29 Both the SVS of meaningfulness, and an ability to view change or stress and the CD-RISC are easy to use; even individuals without as a challenge. A variety of other salient features are also specialized mental health training can be taught to adminis- associated with resilience. Resilient people are capable of ter these self-rated scales in the field. In addition, both engaging the support of others; forming close, secure at- scales can be easily translated into different languages.
tachments with both personal and social networks; and The CD-RISC is a brief, self-rated questionnaire used to striving toward personal or collective goals.23 Such indi- quantify resilience, establish reference values, and evaluate viduals exhibit a greater sense of self-efficacy together the clinical effects of pharmacologic treatment on resil- with a sense of humor when “up against it”; they have ience (scale available upon request from the author).6 It has strong self-esteem and display an action-oriented ap- solid psychometric properties and is able to distinguish proach toward solving problems.23 Resilient individuals between various degrees of illness severity. The scale con- believe that stress can have a strengthening effect, and sists of 25 items, each of which is rated on a 5-point scale COPYRIGHT 2006 PHYSICIANS POSTGRADUA
TE PRESS, INC. COPYRIGHT 2006 PHYSICIANS POSTGRADUATE PRESS, INC.
Figure 1. Effect of Fluoxetine Compared With Placebo on
Figure 2. Effect of Pharmacotherapy or Pharmacotherapy
Stress Vulnerability in Patients With Posttraumatic Stress
Plus CBT on Resilience in U.S. Patients (N = 80) With
Disordera
Posttraumatic Stress Disordera
K.M.C. and J. R. T. Davidson, M.D., unpublished data, January 1, Abbreviation: SVS = Stress Vulnerability Scale.
Abbreviations: CBT = cognitive-behavioral therapy, CD- RISC = Connor-Davidson Resilience Scale, SSRI = selectiveserotonin reuptake inhibitor.
(0–4). Subjects determine their responses according totheir feelings during the month prior to assessment. Thetotal score ranges from 0 to 100, with greater resilience fluoxetine up to 60 mg/day for 12 weeks.18 Significantly reflected in a higher score. When the scale was initially lower median scores on the SVS scale at week 12 described, mean scores ranged from 80.4 for individuals were found in the active drug group compared with the in the general population to 47.8 for patients with PTSD.6 group of patients receiving placebo (3.0 vs. 5.5, p < .01; A short, 2-item version of this scale is also available Figure 1). This significant decrease in stress vulnerability (CD-RISC-2).6 Assessment of the reliability, validity, and implies a “hardiness-promoting” effect of fluoxetine in factor-analytic structure of the CD-RISC found that resil- patients with PTSD, a process referred to elsewhere as ience could be modified and improved by treatment in patients with PTSD, with greater improvements in resil- A recent pilot study17 reported similarly favorable ience corresponding to greater degrees of clinical global outcomes using CD-RISC scores to measure response to fluoxetine and various other treatment strategies in pa- The SVS29 is a 1-item, 11-point, self-rated, visual ana- tients with PTSD. A statistically significant improvement log scale, in which higher scores reflect greater stress vul- with treatment was apparent for 19 of the 25 CD-RISC nerability (e.g., impairment in resilience). Using this scale, items. The 5 items that exhibited the highest statistical sig- individuals can measure their stress-coping abilities over nificance (all p < .0001) involved gaining confidence the previous week. Results from the SVS have suggested from past successes, feeling in control, having the ability that stress coping is more impaired in individuals with to cope with stress, knowing where to turn for help, and PTSD (mean SVS score = 6.3) than in individuals with being able to adapt to change. It was suggested that the 2 other anxiety disorders (mean SVS scores: panic disor- core items most closely reflective of resilience were being der = 5.0, social phobia = 4.8) or in the general population able to adapt to change and tending to bounce back after (mean SVS score = 3.8; K.M.C. and J. R. T. Davidson, M.D., unpublished data, July 1, 2005).
In another study evaluating resilience in patients with PTSD, the median baseline CD-RISC score was 58 (U.S. population reference score = 80).6 Subjects receiv- ing antidepressant medication in conjunction with partici-pation in several clinical trials of PTSD were compared The goals of treatment in patients with PTSD are to al- with those who received combined treatment with a selec- leviate the core symptoms of the disorder and comorbid tive serotonin reuptake inhibitor and cognitive-behavioral disorders, strengthen resilience, improve functioning and therapy. At the end of treatment, median CD-RISC scores quality of life, and ultimately achieve remission. As resil- increased to 74 and 77, respectively (Figure 2; K.M.C. and ience reflects the ability of an individual to cope with J. R. T. Davidson, M.D., unpublished data, January 1, stress and adapt in the aftermath of a traumatic event, im- 2005). These findings demonstrate substantial improve- proved resiliency would be a desirable outcome during ment in resilience after either pharmacotherapy or com- treatment, and this outcome does, in fact, occur.17 bined pharmacotherapy and psychotherapy in persons Responsiveness to the effects of stress was assessed with PTSD to a level close to that observed in the general with the SVS in a randomized, placebo-controlled study of COPYRIGHT 2006 PHYSICIANS POSTGRADUATE PRESS, INC. COPYRIGHT 2006 PHYSICIANS POSTGRADUATE PRESS, INC.
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