Research report
Psychological resilience in OEF–OIF Veterans: Application of a novel classification approach and examination of demographic and psychosocial correlates

https://doi.org/10.1016/j.jad.2011.04.028Get rights and content

Abstract

A growing number of studies have examined the prevalence and correlates of psychopathology in Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF–OIF), but few have examined determinants of resilience in this population. This study employed a novel approach to classify psychological resilience in a cross-sectional sample of OEF–OIF Veterans. A total of 272 predominantly older reserve/National Guard OEF/OIF Veterans completed a mail survey that assessed combat exposure, psychopathology, psychosocial functioning, and aspects of social support. Cluster analysis of scores on measures of combat exposure and PTSD symptoms revealed that a three-group solution best fit the data: Controls (low combat exposure, low PTSD symptoms); PTSD (high combat exposure, high PTSD symptoms); and Resilient (high combat exposure, low PTSD symptoms). Compared to the PTSD group, the Resilient group was more likely to be in a relationship and active duty; they also scored lower on a measure of psychosocial dysfunction, and higher on measures of psychological resilience and postdeployment social support. Logistic regression analysis revealed that being in a relationship, having fewer psychosocial difficulties, and reporting greater perceptions of purpose/control and family support and understanding were significantly associated with resilient group membership. Results of this study demonstrate a novel approach to classifying psychological resilience and suggest that interventions to mitigate psychosocial difficulties, enhance perceptions of purpose and control, and bolster family support and understanding may help promote resilience to combat-related PTSD in OEF–OIF Veterans.

Introduction

A growing body of literature has examined rates and correlates of posttraumatic stress disorder (PTSD) and related psychiatric disorders in Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF–OIF; Hoge et al., 2004, Hoge et al., 2006, Milliken et al., 2007). Results of these studies suggest that PTSD and related disorders such as major depression and generalized anxiety are common in this population, with 1 in 6 OEF–OIF Veterans meeting screening criteria for a psychiatric disorder (e.g., Hoge et al., 2004). While these studies provide a characterization of the prevalence and correlates of psychiatric conditions in OEF–OIF Veterans, little is known about demographic and psychosocial correlates of resilience to combat-related PTSD in this population.

Resilience is defined as the ability to adapt successfully to acute stress and trauma, or more chronic forms of adversity (Bonanno et al., 2006, Larson et al., 2008, Lepore and Revenson, 2006, Masten, 2001). Studies of Vietnam Veterans (King et al., 1998; Waysman et al., 2001), Army Reserve soldiers (Bartone, 1999), and civilian trauma-exposed populations (Bonanno et al., 2006, Bonanno et al., 2007, Butler et al., 2009, Campbell-Sills et al., 2006, Campbell-Sills et al., 2009, New et al., 2009, Simeon et al., 2007) have found that resilient individuals are less likely to develop PTSD and related psychopathology following exposure to a traumatic event. While a number of studies have identified factors associated with resilience in trauma-exposed populations (Bonanno et al., 2006, Feder et al., 2009, Southwick et al., 2005), few have examined factors associated with resilience in OEF–OIF Veterans.

A broad constellation of demographic and psychosocial factors associated with resilience have been identified in trauma-exposed individuals. They include demographic variables such as older age, male gender, Caucasian ethnicity, and greater education; trauma-related factors such as less severe exposure; psychological factors such as dispositional optimism, sense of purpose, extraversion, conscientiousness, moral compass, cognitive flexibility, spirituality, and active coping; and sociocontextual factors such as high psychosocial functioning, supportive relationships, and community resources (Brewin et al., 2000, Bonanno and Mancini, 2008, Bonanno et al., 2006, Bonanno et al., 2007, Bonanno et al., 2008, Butler et al., 2009, Feder et al., 2009, Nasky et al., 2009, Ryff and Keyes, 1995, Simeon et al., 2007, Southwick et al., 2005).

In a recent study, we found that OEF–OIF Veterans who endorsed higher ratings on a self-report measure of psychological resilience (Connor-Davidson Resilience Scale [CD-RISC]; Connor & Davidson, 2003) scored higher on measures of unit cohesion and postdeployment social support, and lower on measures of PTSD, depression, and psychosocial difficulties (Pietrzak et al., 2010). Although these findings provide insight into correlates of self-reported resilience in OEF–OIF Veterans, they do not elucidate specific demographic and psychosocial determinants of the ability to sustain high levels of combat exposure but experience minimal to no combat-related PTSD symptoms (Bonanno et al., 2006, Larson et al., 2008, Lepore and Revenson, 2006, Masten, 2001). This phenomenon, which is also known as stress resistance (Masten, 2001) and psychobiological allostasis (Charney, 2004), is characteristic of individuals who have been tested by trauma or adversity, but who have adapted successfully and experience little to no PTSD symptoms. Another limitation of extant research on resilience is that while it is well known that psychological resilience and social support are negatively associated with PTSD and related psychopathology (Brewin et al., 2000, Butler et al., 2009, Charuvastra and Cloitre, 2008, Pietrzak et al., 2009), specific aspects of these protective factors (e.g., hardiness, purpose/control, community support, instrumental support) have not been systematically characterized in OEF–OIF Veterans. Identification of these dimensions is important, as it may help characterize more specific targets for prevention and treatment interventions that help enhance resilience to combat-related stress in this population.

Definitions of psychological resilience suggest that resilient individuals “bounce back” from a significant stressor or traumatic event (Bonanno et al., 2006, Larson et al., 2008, Lepore and Revenson, 2006, Masten, 2001). For example, according to the American Psychological Association (2009), resilience is defined as “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of stress” (p. 1). This definition suggests significant trauma or stress is a necessary precondition for resilience. Given that stress and traumatic exposures exist on a continuum, individuals who are exposed to stress or trauma may differ in the magnitude and extent to which they are affected. For example, Veterans may be exposed to multiple combat missions over repeated deployments that result in multiple casualties or they may have encountered a single combat mission that was relatively benign in nature and did not result in any casualties. Based on this conceptualization, definitions and operationalizations of resilience should take into consideration the fact that a significant degree of stress, trauma, and/or adversity is a prerequisite for resilience, as individuals who were never really “tested” by a traumatic event cannot really be resilient.

Emerging research on longitudinal trajectories of PTSD and related psychological symptoms in various trauma-exposed samples has employed latent variable modeling (e.g., growth mixture modeling/latent class trajectory modeling) to determine the best-fitting number of classes or groups of trajectories of symptoms over time (e.g., Bonanno; Norris et al., 2009, deRoon-Cassini et al., 2010). These methods are useful in that they allow researchers to model latent trajectories of PTSD and related symptom patterns that may not otherwise be detected using a priori classification methods. An analogous approach that may be used to identify latent classes using cross-sectional data is cluster or latent class analysis. Like latent growth curve/trajectory modeling, these methods help ascertain the best-fitting solution of classes or groups given a set of continuous or categorical variables.

Applying these methods to the study of resilience, one might hypothesize that entering into a cluster or latent class analysis variables that assess the severity of combat exposure (e.g., Combat Experiences Scale) and the severity of combat-related PTSD symptoms (e.g., PTSD Checklist-Military Version) may yield unique group classifications, including, among other possibilities, a "resilient" group (i.e., high combat exposure, low combat-related PTSD symptoms); a "vulnerable" group (i.e., low combat exposure, high combat-related PTSD symptoms); a "PTSD" group (i.e., high combat exposure, high combat-related PTSD symptoms); and a "control" group (i.e., low combat exposure; low combat-related PTSD symptoms). The utility of this approach is that it uses combinations of variables to classify mutually exclusive unknown groups instead of simply dichotomizing samples into individuals with and without PTSD. Correlates of group membership generated by such analyses may differ in etiologically important ways. For example, individuals classified as resilient may have more social support following their return from deployment compared to individuals in the PTSD group, while individuals classified as vulnerable may report lower perceptions of self-efficacy, purpose and control. Finally, one might also enter additional variables (e.g., depression, psychosocial functioning) into this analysis to examine groups of individuals who show differential responses to combat and related traumatic exposures.

The purpose of the present study was to use a cluster analytic approach to examine whether combat exposure and combat-related PTSD symptoms may yield different groups, most notably a resilient group (i.e., high combat exposure, low combat-related PTSD symptoms), in a sample of OEF–OIF Veterans. A secondary aim was to examine demographic and psychosocial characteristics of resilient versus PTSD group membership. We hypothesized that (1) cluster analysis would yield four groups: control, vulnerable, resilient, and PTSD; and that (2) compared to the PTSD group, the resilient group would be more likely to be in a relationship, and that they would score lower on a measure of psychosocial dysfunction, and higher on measures of psychological resilience and social support. Based on previous research (Benight and Bandura, 2004, Luthar, 1991, Regehr et al., 2000, Sharkansky et al., 2000, Ullman et al., 2007, Walsh, 2007), we further hypothesized that perceptions of purpose and control (i.e., coping self efficacy) and greater perceptions of understanding from others would be positively associated with resilient group membership.

Section snippets

Sample

A total of 272 OEF/OIF Veterans completed the Connecticut OEF/OIF Veterans Needs Assessment Survey (dates of military service: 01/03 to 03/07). The purpose of this survey was to identify salient needs of OEF/OIF Veterans in Connecticut and provide recommendations for legislative and public policy initiatives to improve readjustment to civilian life. Potential respondents were identified by inspection of copies of discharge papers (DD-214 s) that were sent to the Commissioner of Veterans Affairs

Cluster analysis of trauma exposure and PTSD severity variables

Cluster analysis of combat exposure (CES) and PTSD severity (PCL-M) scores suggested that a three-group solution best fit the data (BIC = 212.60; BIC ratio of change = .33; ratio of distance measures = 2.37). The first group (N = 134, 50.2%), labeled “Control,” scored low on both the CES (M = 26.37, SD = 8.45) and PCL-M (M = 25.70, SD = 8.03). The second group (N = 72, 27.0%), labeled “PTSD,” scored high on both the CES (M = 50.53, SD = 13.75) and PCL-M (M = 61.81, SD = 11.00). The third group (N = 61, 22.8%), labeled

Discussion

This study examined demographic and psychosocial correlates of resilience to combat-related stress in a sample of predominantly older, white Reservist/National Guard OEF–OIF Veterans. Cluster analysis of scores on measures of combat exposure and PTSD symptoms identified three groups: Control, PTSD, and Resilient. The Resilient group, which represented 23% of the sample, scored highly on a measure of combat exposure, but reported minimal PTSD symptoms. Compared to the PTSD group who also scored

Role of funding sources

None of these funding sources had a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Conflict of Interest

None of the authors have any conflicts of interest.

Acknowledgements

We thank the veterans who participated in this survey. We appreciate the assistance of the Center for Public Policy and Social Research at Central Connecticut State University and the Connecticut Department of Veterans’ Affairs in conducting this research. This work was supported by grants from the State of Connecticut, Department of Mental Health and Addiction Services, the National Center for PTSD, and a private donation.

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