The association of resilience on psychiatric, substance use, and physical health outcomes in combat trauma-exposed military service members and veterans

The role of resilience in the relationship between stress and alcohol

Stress plays a well-documented role in alcohol consumption and the risk for developing alcohol use disorder. The concept of resilience - coping with and successfully adapting to stressful life experiences - has received increasing attention in the field of addiction research in recent decades, and there has been an accumulation of evidence for resilience as a protective factor against problematic alcohol consumption, risk for alcohol use disorder, disorder severity, and relapse. The conceptual and methodological approaches used in the generation of this evidence vary considerably across investigations, however. In light of this, we carried out this review in order to provide a more thorough understanding of the meaning and scope of resilience, what factors contribute to resilience, how it is measured, and how it relates to alcohol-associated phenotypes. Implications for treatment through the use of resilience-building interventions are likewise discussed, as well as implications for future research on the role of resilience in the etiology and clinical outcomes of alcohol use disorder.

Resilience and alcohol use in adulthood in the United States: A scoping review

High levels of alcohol use and the development of alcohol use disorder (AUD) are associated with various adverse consequences. Resilience has been proposed as a protective factor against increased alcohol use, though the existing research is limited by inconsistencies in the conceptualization and measurement of resilience. As such, the current scoping review examined 14 studies on individual, trait-level resilience as a protective factor against alcohol use and related consequences in adults over the age of 21 in the United States. Findings from the included studies generally suggest resilience as a protective factor against various outcomes, though methodological limitations should be considered. Although future research in this area should improve upon methodological limitations, the present review suggests clinical implications of resilience as beneficial in prevention and intervention programming for alcohol use outcomes.

A Longitudinal Investigation of Resilience as a Protective Factor During the COVID-19 Pandemic

COVID-19 is a global stressor that has been shown to impact mental health outcomes. Given that COVID-19 is a unique stressor that has been shown to have mental health consequences, identifying protective factors is imperative. The protective influences of resilience are demonstrated through the extant literature, though less is known about resilience and COVID-19 impact. The current study seeks to expand the existing literature on resilience, and on mental health outcomes influenced by COVID-19, by longitudinally investigating relative resilience as a buffer against posttraumatic stress disorder (PTSD) symptoms and alcohol consumption, in the wake of a global pandemic. Participants included 549 undergraduates with a history of lifetime trauma exposure. Using a longitudinal path model, we tested the interaction between relative resilience (i.e., an individual's deviation from distress levels predicted by prior trauma exposure relative to other individuals in the same cohort) and COVID-19 impact domains (i.e., social media use, worry, exposure, change in substance use, and housing/food insecurity) on PTSD symptoms and alcohol consumption. Findings demonstrate a significant interaction between the COVID-19 worry impact domain and baseline resilience on later PTSD symptoms, whereby COVID-19 worry impacts PTSD symptoms at low levels of resilience (β = .26, p < .001), marginally impacts PTSD symptoms at mean levels of resilience (β = .09, p = .05), and does not impact PTSD symptoms at high levels of resilience (β = -.08, p = .16). There were no significant main effects nor interaction effects of resilience on alcohol consumption. This article adds to the literature on resilience and COVID-19 through examining both internalizing (i.e., PTSD) and substance use outcomes, using longitudinal data, and using a quantitative measure of resilience.

Modeling the association between and predictors of two constructs of resilience

PURPOSE

Resilience serves as a protective factor against adverse outcomes following exposure to traumatic events. The extant literature focuses on psychiatric resilience in the context of internalizing symptoms, though resilience is also important in relation to externalizing symptoms. Research is needed to clarify the predictors of resilience across contexts. The aims of the current study are twofold: 1. Determine the association between psychiatric resilience (PR) and alcohol resistance (AR) and 2. Test for differential prediction of each form of resilience by exogenous predictors.

METHODS

The sample (n = 7585) was drawn from the Virginia Adult Twin Studies of Psychiatric and Substance Use Disorders (VATSPSUD). Participants completed measures of internalizing symptoms, exposure to stressful life events, DSM alcohol abuse and dependence symptoms, maximum alcohol consumption, personality variables, and social support. All cross-sectional, structural equation modeling (SEM) analyses were conducted using Mplus software version 8.2.

RESULTS

A single common factor model provided adequate fits for both PR and AR. In the full measurement model the correlation between the two resilience factors was estimated (r = 0.28, SE = 0.018, p < 0.001). Neuroticism and mastery predicted AR and PR, but differentially, with a stronger effect size for PR (neuroticism: B = 0.35, p < 0.001; mastery: B = - 0.36, p < 0.001). The positive social support factor did not predict either resilience variable, while interpersonal conflict was associated with both (AR = 0.09, p < 0.001; PR = 0.07, p < 0.001).

CONCLUSIONS

Findings extend the current literature on resilience in two ways. First, rigorous measurement model based definitions of two resilience variables are specified. Second, external validation of the AR and PR constructs is carried out using latent variable modeling techniques. The modest correlation suggests resilience may not be well-characterized by a single general attribute. Findings provide further evidence for predictors of resilience by way of displaying differential patterns of prediction effect sizes of PR and AR.

Roles of alcohol use disorder and resilience in risk of suicide attempt in men: A Swedish population-based cohort

INTRODUCTION

Alcohol use disorder (AUD) has been identified as a strong risk factor for suicide attempt. However, few studies have considered protective factors that may moderate this association, such as resilience.

METHODS

We used longitudinal nationwide Swedish data of 903,333 males born 1960-1980 and 48,285 males born 1949-1951. We performed Cox proportional hazards models to test the role of AUD, resilience, and their interaction on risk for suicide attempt. We used co-relative models to account for familial factors.

RESULTS

Alcohol use disorder was strongly associated with increased risk of suicide attempt [hazard ratio (HR) = 12.22], while resilience was associated with reduced risk (HR = 0.73). Multiplicative interaction (HR = 1.21) showed that, in the context of AUD, the protective role of resilience on risk of suicide attempt was somewhat attenuated. Co-relative analyses supported both familial liability and a possible causal pathway between AUD, resilience, and suicide attempt. In the cohort born 1949-1951, resilience subcomponents-social maturity, interests, psychological energy, home conditions, and emotional control-were all associated with reduced suicide attempt risk (HRs between 0.63 and 0.74).

CONCLUSION

While resilience is associated with reduced risk of suicide attempt, this effect is less pronounced in the context of AUD. These associations are potentially causal.

The role of trauma, social support, and demography on veteran resilience

BACKGROUND

Historically, resilience has often been conceptualized as the sustained lack of symptoms following trauma exposure. In line with a novel conceptualization of resilience as being dynamic over lifespan, determined by interacting biological and environmental factors, we examined the VA Mid-Atlantic Post Deployment Mental Health Repository (PDMH) comprised of 3876 US Military Veterans with and without PTSD diagnoses.

METHODS

We performed regression modelling to study the relationship between resilience (measured with Connor Davidson Resilience Scale; CD-RISC), posttraumatic stress disorder (PTSD) severity (Davidson Trauma Scale; DTS), social support (Medical Outcome Study Social Support Survey; MOSSS), combat exposure (Combat Exposure Scale; CES), childhood trauma (Trauma Life Events Questionnaire; TLEQ), and demographic factors. CD-RISC was positively correlated with years of education and negatively correlated with DTS, CES and TLEQ scores.

RESULTS

We found an interaction between CD-RISC and CES in predicting PTSD severity (Davidson Trauma Scale). Specifically, high resilience predicted lower PTSD symptom severity than low resilience, this relationship was amplified with increasing levels of combat exposure. Structural equation modelling (SEM) identified an optimal latent variable that represents resilience and relationships between latent variables for resilience, trauma, and illness. We derived a resilience latent variable composed of age, education level, MOSSS and race.

CONCLUSIONS

Our results support a conceptualization of resilience as a multifactorial determinant that coexists with PTSD, a state rather than trait variable, and can be quantified by biological and behavioural metrics.

HIGHLIGHTS

• Historically, resilience has often been conceptualized as the sustained lack of symptoms following trauma exposure.• We examined the VA Mid-Atlantic Post Deployment Mental Health Repository (PDMH) comprised of 3876 US Military Veterans.• We found an interaction effect between CD-RISC and CES in predicting PTSD severity (Davidson Trauma Scale).

Psychological Resilience in West Point Graduates: Results From a Nationally Representative Study

Background: The purpose of this study was to examine factors associated with psychological resilience in a nationally representative sample of West Point graduates. Aims: The aims of this study were to (a) employ a dimensional approach to operationalizing psychological resilience in a trauma-exposed population that had been highly trained and educated in persisting in the face of stress, was previously unstudied, and in which we could examine correlates of resilience, (b) identify key psychosocial factors, character traits, health variables, military experiences, and coping strategies as potential correlates of psychological resilience; and (c) examine whether reported gender moderated any of these associations in this population. Methods: A nationally representative sample of 1342 West Point graduates after gender integration from classes 1980 to 2011 were surveyed. Psychological resilience was operationalized using a discrepancy-based approach in which a measure of composite psychological distress (current posttraumatic stress disorder, generalized anxiety and depression symptoms) was regressed on measures of cumulative trauma burden. A multivariable linear regression model was then employed to identify factors that were independently associated with psychological resilience scores. Results: Purpose in life (29.8% of relative variance explained [RVE]), fewer perceived negative experiences in the military (20.6% RVE), social support (9.6% RVE), and grit (9.5% RVE) were the strongest correlates of psychological resilience scores for both women and men. Time in service was positively associated with resilience in women only. Conclusion: This study identifies key correlates of psychological resilience in West Point graduates, individuals who are highly trained to persevere in the face of stress and then were trauma-exposed. Most of these factors are modifiable and can be targeted in stress prevention and treatment interventions, especially for high-stress professions such as the military, frontline health care providers, and first responders.

Resilience to traumatic stress in U.S. military veterans: Application of a novel classification approach in a nationally representative sample

Resilience has been of particular interest to researchers and clinicians focused on response to trauma. In the current study, we employed a novel, discrepancy-based psychiatric resilience (DBPR) analytic approach to operationalizing resilience and examined its relation to potentially protective psychosocial factors in a nationally representative sample of U.S. veterans (N = 2704). Cumulative lifetime trauma burden, severity of PTSD symptoms, and protective factors such as personality characteristics (e.g., conscientiousness), protective psychosocial characteristics (e.g., purpose in life), and social connectedness (e.g., secure attachment style) were assessed. PTSD Checklist (PCL) scores were regressed onto cumulative trauma burden for the entire sample and a predicted PCL score was generated for each veteran. Resilience was operationalized as a lower actual relative to predicted PCL score. Results of a relative importance analysis revealed that somatic symptoms (22.5% relative variance explained [RVE]), emotional stability (22.4% RVE), and a secure attachment style (14.1%) explained the majority of the variance in resilience scores. These results demonstrate the utility of a DBPR approach to operationalizing resilience in U.S. military veterans. They also identify potentially modifiable psychosocial factors that may be bolstered in prevention and treatment efforts designed to mitigate the negative effects of trauma and promote resilience in this population.

Ecological Momentary Mood, Resilience, and Mental Health Status as Predictors of Quality of Life Among Young Adults Under Stress: A Structural Equation Modeling Analysis

Multiple internal factors, such as psychological resilience and mental health status, have been shown to contribute to overall quality of life (QoL). However, very few studies to date have examined how these factors contribute to QoL of youth and young adults in a stressful situation. Here, we studied the contribution of these factors, as well as of ecological momentary mood assessment, to QoL of young army recruits during their Basic Training Combat (BCT). To this end, we collected data from 156 male and female soldiers in a mixed-gender unit in the Israel Defense Forces (IDF). Using a mobile app installed on participants' phones, participants provided self-reports regarding their mental health status and psychological resilience at baseline, and QoL 2 weeks later. Momentary mood reporting was further collected during the 2-week interval period using a daily self-report mood scale (IMS-12). Structural equation modeling (SEM) was used to examine the interrelationships among the study variables based on a hypothesized model. We found that a model with all factors (gender, resilience, mental health status and momentary mood) provided a good fit for the data based on its fit indices [χ2(38) = 47.506, p = 0.139, CFI = 0.979, NFI = 0.910, RMSEA = 0.040, TLI = 0.964]. However, the only direct contributors to QoL were gender and momentary mood, accounting together for 61.5% of the variance of QoL. Psychological resilience and mental health status contributed to QoL only indirectly, through their associations with momentary mood. Collectively, these results highlight the importance of ecological momentary assessment of mental-health related factors such as mood to the prediction of QoL in young adults under stress. These findings may have broader implications for monitoring and improvement of well-being in young healthy populations as well as in clinical ones.

Longitudinal Examination of the Impact of Resilience and Stressful Life Events on Alcohol Use Disorder Outcomes

Stressful life events (SLEs) are a risk factor for alcohol use problems, and there is a need for identification of factors that may offset this risk. Resilience is uniquely, inversely associated with alcohol use, but there remains a dearth of research examining the buffering effect of resilience toward alcohol use problems in the context of SLEs. Objectives: This study used prospective data from an epidemiological twin sample (N = 7441) to test whether resilience at Time 1 would act as a buffer for new onset SLEs (e.g. assault, marital problems) against risk for alcohol dependence (AD) symptoms at Time 2. Results: The final model, adjusted for familial relatedness and controlling for demographic covariates and Time 1 (lifetime) AD symptoms, identified significant main effects of resilience and SLEs; those with greater resilience at Time 1 reported fewer symptoms (β=-.087, p<.001) and those with greater new-onset SLEs reported greater symptoms (β=.116, p<.001) at Time 2. However, there was no significant interaction (β=-.008, p>.05). Conclusions: Although findings further support the association of resilience and SLEs with AD, results do not support the conceptualization of resilience as a buffer against the impact of future life stressors on alcohol use outcomes. This suggests other factors may be more relevant for understanding protective factors for alcohol use problems or the relation between resilience and SLEs on alcohol use outcomes.

Psychological resilience: an update on definitions, a critical appraisal, and research recommendations

Background: The ability to resist adverse outcomes, or demonstrate resilience after exposure to trauma is a thriving field of study. Yet ongoing debate persists regarding definitions of resilience, generalizability of the extant literature, neurobiological correlates, and a consensus research agenda. Objectives: To address these pressing questions, Drs. Christy Denckla and Karestan Koenen (co-chairs) convened a multidisciplinary panel including Drs. Dante Cicchetti, Laura Kubzansky, Soraya Seedat, Martin Teicher, and David Williams at the 2019 annual meeting of the International Society for Traumatic Stress Studies (ISTSS). Questions included (1) how have definitions of resilience evolved, (2) what are the best approaches to capture the complexity of resilience processes, and (3) what are the most important areas for future research? Methods: The proceedings of this panel are summarized in this report, and prominent themes are synthesized and integrated. Results: While different definitions emerged, all shared a focus on conceptualizing resilience at multiple levels, from the biological to the social structural level, a focus on the dynamic nature of resilience, and a move away from conceptualizing resilience as only an individual trait. Critical areas for future research included 1) focused efforts to improve assessment that has international and cross-cultural validity, 2) developing within-study designs that employ more intensive phenotyping strategies, 3) examining outcomes across multiple levels and domains, and 4) integrating conceptualizations of resilience from the individual-level to the larger social context at the population health level. Conclusion: Increasingly sophisticated and nuanced conceptual frameworks, coupled with research leveraging advances in genetics, molecular biology, increased computational capacity, and larger, more diverse datasets suggest that the next decade of research could bring significant breakthroughs.

Short-Term and Long-Term Resilience Among At-Risk Adolescents: The Role of Family and Community Settings

Objective: Given the severe consequences associated with maltreatment, establishing an understanding of pathways to resilience among trauma-exposed youth is a critical public health aim. Longitudinal research has either examined short-term or long-term responses to traumatic events, which prevents testing for a) individual differences between resilience subtypes and b) consistency of short-term, resilient responses over time. Additionally, post-traumatic stress and depression represent the two most common symptom patterns in youth exposed to maltreatment, however few studies have simultaneously investigated resilience to these outcomes. In response, the current study employs a dimensional analytic approach to distinguish between short-term (the ability to demonstrate adaptive responses to ongoing adversities) and long-term (lack of distress over several years in response to a prior adversity) resilience. Consistent with an ecological perspective, the study examines whether family- and community-level protective factors are similarly or uniquely associated with different resilience subtypes.Method: Participants included 943 individuals (469 male, 474 female) from a nationally-representative, at-risk sample of adolescents who completed self-report measures of maltreatment exposure, depressive symptoms and post-traumatic stress symptoms at ages 12, 16, and 18. During the age 12 visit, participants' caregivers completed self-report measures of family routines and neighborhood social cohesion.Results: Overall, we found that family routines uniquely buffered against trauma-related distress across resilience conceptualizations, while social cohesion played a role in short-term resilience to depressive symptoms (p <.05). Participant gender did not moderate these results (p > .05).Conclusion: These findings highlight the importance of understanding resilience dimensionally for adolescents exposed to maltreatment.