Research reportPsychological resilience in OEF–OIF Veterans: Application of a novel classification approach and examination of demographic and psychosocial correlates
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.
References (66)
- et al.
Effects of perceived control and cognitive coping on endocrine stress responses to pharmacological activation
Biol. Psychiatry
(2008) - et al.
Social cognitive theory of posttraumatic recovery: the role of perceived self-efficacy
Behav. Res. Ther.
(2004) - et al.
Relationship of resilience to personality, coping, and psychiatric symptoms in young adults
Behav. Res. Ther.
(2006) - et al.
Correlates of functional impairment in treatment-seeking survivors of mass terrorism
Behav. Ther.
(2009) - et al.
A Functional magnetic resonance imaging study of deliberate emotion regulation in resilience and posttraumatic stress disorder
Biol. Psychiatry
(2009) - et al.
Looking for resilience: understanding the longitudinal trajectories of responses to stress
Soc. Sci. Med.
(2009) - et al.
Psychosocial buffers of traumatic stress, depressive symptoms, and psychosocial difficulties in Veterans of Operations Enduring Freedom and Iraqi Freedom: The role of resilience, unit support, and postdeployment social support
J. Affect. Dis.
(2010) - et al.
Factors associated with resilience in healthy adults
Psychoneuroendocrinology
(2007) - et al.
Multidimensional assessment of resilience in mothers who are child sexual abuse survivors
Child Abuse Negl.
(2005) - et al.
Trauma, resilience, and recovery in a high-risk African-American population
Am. J. Psychiatry
(2008)
Risk and resilience in canine search and rescue handlers after 9/11
J. Trauma. Stress
The road to resilience. American Psychological Association Help Center
Coping responses and posttraumatic stress symptomatology in urban fire service personnel
J. Trauma. Stress
Psychological resilience after disaster: New York City in the aftermath of the September 11th terrorist attack
Psychol. Sci.
What predicts psychological resilience after disaster? The role of demographics, resources, and life stress
J. Consult. Clin. Psychol.
Psychological resilience and dysfunction among hospitalized survivors of the SARS epidemic in Hong Kong: a latent class approach
Health Psychol.
The human capacity to thrive in the face of potential trauma
Pediatrics
Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults
J. Consult. Clin. Psychol.
Psychosocial predictors of resilience after the September 11, 2001 terrorist attacks
J. Nerv. Ment. Dis.
Demographic and childhood environmental predictors of resilience in a community sample
J. Psychiatr. Res.
Salutogenic childhood factors reported by middle-aged individuals. Follow-up of the children from the Lundby study grown up in families experiencing three or more childhood psychiatric risk factors.
Eur. Arch. Psychiatry Clin. Neurosci.
Psychobiological mechanisms of resilience and vulnerability: implications for successful adaptation to extreme stress
Am. J. Psychiatry
Social bonds and posttraumatic stress disorder
Annu. Rev. Psychol.
Statistical power analysis for the behavioral sciences
Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC)
Depress. Anxiety
Psychopathology and resilience following traumatic injury: A latent growth mixture model analysis
Rehabil. Psychol.
Detecting Alcoholism: The CAGE Questionaire
JAMA.
Psychobiology and molecular genetics of resilience
Nat. Rev. Neurosci.
Does hardiness contribute to mental health during a stressful real-life situation? The roles of appraisal and coping
J. Pers. Soc. Psychol.
Parent and child views of parent–child relationship qualities and resilient outcomes among urban children
J. Child. Psychol. Psychiatry.
Psychological consequences of the Bam earthquake on professional and nonprofessional helpers
J. Trauma. Stress
Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care
N. Engl. J. Med.
Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan
JAMA
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