The three axioms of resilience.

This article summarizes the growing literature on resilience in the face of aversive and potentially traumatic events (PTEs) in three basic axioms: (a) resilience is a common outcome, 2) there are no "key" traits to resilience (resilience is not a type), and (c) resilient outcomes occur through flexible self-regulation. The first axiom highlights the limitation of a traditional, binary view of trauma in terms of the presence-absence of posttraumatic stress disorder, emphasizing instead the heterogeneity of trauma outcomes. Four prototypical trajectories are reviewed: chronic symptoms; delayed symptoms; recovery; and the most common trajectory, resilience. The second axiom reviews the paradoxical inability of known correlates of resilience to adequately predict resilient outcomes. Resilience is instead described as a multifaceted phenomenon with no singular set of key traits, as various factors contribute to resilient outcomes in complex ways. The third axiom provides an explanation of how resilience can emerge from this complex array by introducing the concept of flexible self-regulation. The flexibility mindset is described as providing the motivation for flexible responding. The flexibility sequence is described as explaining the mechanisms underlying flexibility in terms of three serial stages: context sensitivity, strategy repertoire, and feedback adjustment. The final section briefly considers clinical implications.

Reciprocal association between pain and quality of life after newly acquired spinal cord injury.

PURPOSE: Pain is highly prevalent in spinal cord injury (SCI) and a key determinant of quality of life (QoL). This is the first study to examine reciprocal associations between pain and QoL in patients undergoing their first inpatient rehabilitation after SCI. METHODS: Longitudinal data, with three measurement time points (1 month and 3 months after SCI onset, and at discharge from inpatient rehabilitation) from the Inception Cohort of the Swiss Spinal Cord Injury Cohort Study. Participants were 381 individuals aged ≥ 16 years with a newly diagnosed traumatic or non-traumatic SCI. 75.1% were male and the average age was 53.2 years. Random intercept cross-lagged panel models were conducted to examine the reciprocal association between pain intensity and QoL, as measured with the International SCI QoL Basic Data Set three individual items (satisfaction with life, physical health, and psychological health) and total score (mean of the three individual items). RESULTS: Both item and total QoL scores increased over time. 1 month: 5.3 (SD = 2.7), 3 months: 5.9 (SD = 2.3), discharge: 6.6 (SD = 2.0). Participants reported relatively low levels of pain intensity that remained stable over the course of inpatient rehabilitation. 1 month: 2.7 (SD = 2.3), 3 months: 2.6 (SD = 2.4), discharge: 2.7 (SD = 2.5). There were no significant cross-lagged associations between QoL and pain intensity across time. CONCLUSION: Results indicate that pain intensity does not predict changes in QoL during first rehabilitation, and vice versa. Associations between pain intensity and QoL reported by previous studies may be attributable to individual characteristics and timely events that simultaneously influence pain and QoL.

Internal consistency and convergent validity of the International Spinal Cord Injury Quality of Life Basic Data Set at discharge from first rehabilitation.

STUDY DESIGN: This study is a cross-sectional analysis using data from the Swiss Spinal Cord Injury Cohort Study. OBJECTIVES: To examine internal consistency and convergent validity of the International Spinal Cord Injury Quality of Life Basic Data Set (QoL-BDS) at discharge from first inpatient rehabilitation. SETTING: The study was performed at four rehabilitation centers in Switzerland. METHODS: Participants were Swiss residents aged over 16 years newly diagnosed with traumatic or non-traumatic spinal cord injury (SCI). Measures included the QoL-BDS, World Health Organization Quality of Life (WHOQOL) items, Hospital Anxiety and Depression Scale (HADS), and Spinal Cord Independence Measure III (SCIM). RESULTS: A total of 495 participants were included. In all, 57% had a traumatic SCI, 71.1% a motor complete SCI, and 33.3% had tetraplegia. Mean age was 53 (SD = 16.4) years and 68% were male. No floor or ceiling effects were found. Inter-correlations were strong (0.73-0.80) and Cronbach's alpha was good (0.88). QoL-BDS mean scores were 6.4 (SD = 2.2) for life satisfaction, 5.8 (SD = 2.4) for physical health, 6.9 (SD = 2.4) for psychological health, and 6.4 (SD = 2.1) for total QoL. Correlations with reference measures were strongest for QoL-BDS total and WHOQOL general quality of life (r = 0.67), QoL-BDS physical health and WHOQOL health and daily activities (r = 0.64 and 0.53), and QoL-BDS psychological health and HADS depression and anxiety (r = -0.64 and -0.69). SCIM correlated weakly with all QoL-BDS items. CONCLUSIONS: The QoL-BDS revealed no floor or ceiling effects and demonstrated good internal consistency and convergent validity in individuals with SCI assessed at discharge from first rehabilitation. This study supports the clinical routine use of the QoL-BDS.

Longitudinal measurement invariance of the international spinal cord injury quality of life basic data set (SCI-QoL-BDS) during spinal cord injury/disorder inpatient rehabilitation.

PURPOSE: This study aimed at testing the internal consistency and longitudinal measurement invariance of a brief quality of life questionnaire-the spinal cord injury quality of life basic data set (SCI-QoL-BDS)-among individuals with spinal cord injury/disorder undergoing first inpatient rehabilitation. METHODS: Longitudinal data from the Swiss spinal cord injury inception cohort study were used. Participants (n = 218) completed the SCI-QoL-BDS at one and three months post injury and at discharge. The SCI-QoL-BDS consists of three items assessing satisfaction with life as a whole, physical health, and psychological health. Internal consistency was examined at each time point and longitudinal measurement invariance was tested using longitudinal confirmatory factor analysis. RESULTS: Internal consistency coefficients ranged between .82 and .90. The confirmatory factor analysis revealed invariance of the factor structure and of all factor loadings across time. Additionally, all item intercepts except the one of satisfaction with physical health were invariant across time, suggesting partial intercept invariance of the SCI-QoL-BDS. Indeed, a response shift was observed in satisfaction with physical health. This item was evaluated more negatively in the early phase of inpatient rehabilitation, indicating the change of the evolving physical situation after the onset of a spinal cord injury. CONCLUSION: The SCI-QoL-BDS is a consistent and valid measure to assess quality of life among individuals undergoing first spinal cord injury/disorder inpatient rehabilitation. However, we recommend using latent variable frameworks instead of mean scores when examining longitudinal changes in the measure to account for potential response shift.

Mindfulness predicts less depression, anxiety, and social impairment in emergency care personnel: A longitudinal study.

Medical personnel working in emergency rooms (ER) are at increased risk of mental health problems and suicidality. There is increasing evidence that mindfulness-based interventions can improve burnout and other mental health outcomes in health care providers. In contrast, few longitudinal prospective studies have examined protective functions of dispositional mindfulness in this population. The objective of this study was to examine whether mindfulness prospectively predicts anxiety, depression, and social impairment in a sample of emergency care professionals. The authors administered online surveys to ER personnel prior to work in ER, and at 3 and 6 months follow up. Participants were 190 ER personnel (73% residents, 16% medical students, 11% nurses). Linear mixed effects regression was used to model longitudinal 3-month and 6-month follow up of depression, anxiety, and social impairment. Predictors included time-varying contemporaneous work stressors, perceived social support at work and life events, and baseline dispositional mindfulness, demographics, and workplace characteristics. Mindfulness indexed when starting ER work predicted less depression, anxiety, and social impairment 6 months later. Mindfulness remained a strong predictor of mental health outcomes after controlling for time-varying stressful events in emergency care, negative life events, and social support at work. Mindfulness moderated the adverse impact of poor social support at work on depression. To our knowledge, this is the first longitudinal study to show that mindfulness prospectively and robustly predicts anxiety, depression, and social impairment. Results support the role of mindfulness as a potential resilience factor in at-risk health care providers.

Outside the Eye of the Storm: Can Moderate Hurricane Exposure Improve Social, Psychological, and Attachment Functioning?

High-intensity disaster can harm psychological functioning. Could moderate-intensity disaster improve psychological and attachment functioning through its effects on social functioning? We used a prospective quasi-experimental cohort design to investigate this possibility among college students. Hurricane cohort participants (N = 209) completed assessments before, 2 weeks, and 6 weeks after Hurricane Sandy. Two matched comparison cohorts (Ns > 140) were assessed 4 months and 1 year later. The hurricane cohort, in contrast to matched comparison cohorts, reported increased social support, reduced global distress, reduced negative emotion, and reduced attachment avoidance at the end of the semester. Increased social support mediated the relationship between hurricane cohort and reduced global distress, negative emotion, attachment avoidance, and attachment anxiety, and increased positive emotion and self-esteem at 6 weeks poststorm. The results suggest moderate disaster exposure can benefit short-term social, psychological, and attachment functioning, underscoring the critical role of the social context in stress adaptation.

Emotional conflict adaptation predicts intrusive memories.

Why do some individuals experience intrusive emotional memories following stressful or traumatic events whereas others do not? Attentional control may contribute to the development of such memories by shielding attention to ongoing tasks from affective reactions to task-irrelevant emotional stimuli. The present study investigated whether individual differences in theability to exert cognitive control are associated with experiencing intrusive emotional memories after laboratory trauma. Sixty-one healthy women provided self-reported and experimentally derived measures of attentional control. They then viewed a trauma film in the laboratory and recorded intrusive memories for one week using a diary. Gaze avoidance during trauma film exposure was associated with more intrusive memories. Greater attentional control over emotion prior to film viewing, as assessed with the experimental task, predicted fewer intrusive memories while self-reported attentional control was unrelated to intrusive memories. Preexisting capacity to shield information processing from distraction may protect individuals from developing intrusive emotional memories following exposure to stress or trauma. These findings provide important clues for prevention and intervention science.

Self-compassion and emotional invalidation mediate the effects of parental indifference on psychopathology.

This study investigated whether self-compassion and emotional invalidation (perceiving others as indifferent to one's emotions) may explain the relationship of childhood exposure to adverse parenting and adult psychopathology in psychiatric outpatients (N=326). Path analysis was used to investigate associations between exposure to adverse parenting (abuse and indifference), self-compassion, emotional invalidation, and mental health when controlling for gender and age. Self-compassion was strongly inversely associated with emotional invalidation, suggesting that a schema that others will be unsympathetic or indifferent toward one's emotions may affect self-compassion and vice versa. Both self-compassion and emotional invalidation mediated the relationship between parental indifference and mental health outcomes. These preliminary findings suggest the potential utility of self-compassion and emotional schemas as transdiagnostic treatment targets.

Frozen moments: flashback memories of critical incidents in emergency personnel.

BACKGROUND: Emergency Department personnel regularly face highly stressful situations or critical incidents (CIs) that may subsequently be recalled as unbidden intrusive memories. In their most extreme form, such memories are reexperienced as if they were happening again in the present, as flashbacks. This study examined (1) which CIs are associated with flashback memories; (2) candidate person and work-related features that predict flashback memories; and (3) the association between flashback memories and anxiety, depression, and emotional exhaustion. METHODS: Emergency nurses (N = 91; 80.2% female) were recruited from two urban teaching hospitals and filled in self-report questionnaires. RESULTS: A majority (n = 59, 65%) experienced intrusive memories; almost half of the sample reported that their memories had flashback character. Those involved in resuscitations in the past week were at a fourfold risk for experiencing flashbacks. Having worked more consecutive days without taking time off was associated with a somewhat lower incidence of flashbacks. Moreover, older individuals who reported more work-related conflicts were at greater risk for experiencing flashback memories than their younger colleagues with heightened work conflict and flashback memory scores, respectively. Flashback memories were associated with heightened symptoms of anxiety, depression, and emotional exhaustion. CONCLUSIONS: The present findings have implications for evidence-based health promotion in emergency personnel and other individuals regularly exposed to CIs.

Protective benefits of mindfulness in emergency room personnel.

BACKGROUND: Recent meta-analyses have found that mindfulness practice may reduce anxiety and depression in clinical populations and there is growing evidence that mindfulness may also improve well-being and quality of care in health professionals. This study examined whether mindfulness protects against the impact of work-related stress on mental health and burnout in emergency room (ER) nurses. METHODS: ER nurses (N=50) were recruited from an urban teaching hospital in Switzerland and completed a survey on work-related stressors, mindfulness, burnout, depression, and anxiety. RESULTS: The most frequently reported work-related stressor was interpersonal conflict. Nurses working more consecutive days since last taking time off were at greater risk for depression and those reporting more work-related interpersonal conflicts were at greater risk for burnout. Mindfulness was associated with reduced anxiety, depression, and burnout. Mindfulness was a significant predictor of anxiety, depression, and burnout and moderated the impact of work-related stressors on mental health and burnout. LIMITATIONS: The sample is limited to nurses and results need to be replicated in other groups (e.g., medical staff or ambulance workers). We assessed clinical symptoms with questionnaires and it would be desirable to repeat this assessment with clinical diagnostic interviews. CONCLUSIONS: The findings have implications for stress management in ER nurses and health professionals working in comparable settings (e.g., urgent care). The robust associations between mindfulness and multiple indices of psychological well-being suggest that ER staff exposed to high levels of occupational stress may benefit from mindfulness practice to increase resistance to mental health problems and burnout.

Borderline personality disorder, exposure to interpersonal trauma, and psychiatric comorbidity in urban primary care patients.

OBJECTIVE: Few data are available on interpersonal trauma as a risk factor for borderline personality disorder (BPD) and its psychiatric comorbidity in ethnic minority primary care populations. This study aimed to examine the relation between trauma exposure and BPD in low-income, predominantly Hispanic primary care patients. METHOD: Logistic regression was used to analyze data from structured clinical interviews and self-report measures (n = 474). BPD was assessed with the McLean screening scale. Trauma exposure was assessed with the Life Events Checklist (LEC); posttraumatic stress disorder (PTSD) was assessed with the Lifetime Composite International Diagnostic Interview, other psychiatric disorders with the SCID-I, and functional impairment with items from the Sheehan Disability Scale and Social Adjustment Scale Self-Report (SAS-SR). RESULTS: Of the 57 (14%) patients screening positive for BPD, 83% reported a history of interpersonally traumatic events such as sexual and physical assault or abuse. While interpersonal trauma experienced during adulthood was as strongly associated with BPD as interpersonal trauma experienced during childhood, noninterpersonal trauma was associated with BPD only if it had occurred during childhood. The majority (91%) of patients screening positive for BPD met criteria for at least one current DSM-IV Axis I diagnosis and exhibited significant levels of functional impairment. CONCLUSION: Increased awareness of BPD in minority patients attending primary care clinics, high rates of exposure to interpersonal trauma, and elevated risk for psychiatric comorbidity in this population may enhance physicians' understanding, treatment, and referral of BPD patients.

Functional impairment in adults with past posttraumatic stress disorder: findings from primary care.

BACKGROUND: Although many patients with posttraumatic stress disorder (PTSD) experience a reduction in posttraumatic symptoms over time, little is currently known about the extent of their residual functional impairment. This study examines functional impairment in primary care patients with a history of PTSD as compared to patients with current PTSD, and those who never developed PTSD following exposure to trauma. METHODS: The sample consisted of 321 trauma-exposed low-income, predominantly Hispanic adults attending a large urban primary care practice. PTSD was assessed with the Lifetime Composite International Diagnostic Interview and other psychiatric disorders with the SCID-I. Physical and mental health-related quality of life was assessed with the Medical Outcome Health Survey (SF-12), and functional impairment with items from the Sheehan Disability Scale and Social Adjustment Scale Self-Report. RESULTS: Logistic regression analyses controlling for gender, psychiatric comorbidity, and interpersonal traumas showed that although patients with past PTSD function significantly better than patients with current PTSD, they experience persisting deficits in mental health-related quality of life compared to trauma-exposed patients who never developed PTSD. Overall, results revealed a continuum of severity in psychiatric comorbidity, functioning, and quality of life, with current PTSD associated with the most impairment, never having met criteria for PTSD with the least impairment, and history of PTSD falling in between. CONCLUSIONS: In this primary care sample, adults with a history of past PTSD but no current PTSD continued to report enduring functional deficits, suggesting a need for ongoing clinical attention.

Resilience to loss and potential trauma.

Initial research on loss and potentially traumatic events (PTEs) has been dominated by either a psychopathological approach emphasizing individual dysfunction or an event approach emphasizing average differences between exposed and nonexposed groups. We consider the limitations of these approaches and review more recent research that has focused on the heterogeneity of outcomes following aversive events. Using both traditional analytic tools and sophisticated latent trajectory modeling, this research has identified a set of prototypical outcome patterns. Typically, the most common outcome following PTEs is a stable trajectory of healthy functioning or resilience. We review research showing that resilience is not the result of a few dominant factors, but rather that there are multiple independent predictors of resilient outcomes. Finally, we critically evaluate the question of whether resilience-building interventions can actually make people more resilient, and we close with suggestions for future research on resilience.

A longitudinal study of posttraumatic stress disorder, depression, and generalized anxiety disorder in Israeli civilians exposed to war trauma.

This 3-wave longitudinal study examined the mental health consequences of the Israel-Gaza 2008-2009 war among young Israeli civilians. Data on posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD), and their predictors were collected during the war, and 2 and 4 months after cease fire. Results showed a sharp decline in symptom levels of PTSD, MDD, and GAD over time. Perceived social support during the war moderated the effects of immediate emotional response on subsequent levels of PTSD, MDD, and GAD. These findings underscore the importance of social support and immediate emotional response to trauma in predicting trauma-related psychopathology, and highlight the potential need for providing early care to exposed individuals exhibiting immediate and severe emotional responses.

Expressive flexibility.

Previous research has examined the consequences of either expressing or suppressing emotion using between-subjects designs. However, emotion theorists have argued that adaptation depends not so much on one regulatory process but rather on the ability to flexibly regulate emotion in accord with situational demands. To test this idea, Bonanno, Papa, Lalande, Westphal, and Coifman (2004) developed a within-subjects experimental paradigm to measure expressive flexibility (EF) and showed that EF predicted better self-reported adjustment over a 2-year period. The current investigation extends this research by (1) demonstrating the stability of EF across a 3-year period, (2) replicating the association between EF and positive adjustment using a more objective measure of adjustment (obtained from participants' close friends rather than based on self-report), and (3) by showing that the positive relation between EF and adjustment was particularly salient in the context of high levels of cumulative life stress when EF was measured under conditions of immediate threat (presence of a subliminal threat prime).

Trauma, resilience, and recovery in a high-risk African-American population.

OBJECTIVE: Despite increased risk for psychiatric disorders after trauma exposure, many people are able to adapt with minimal life disruption, and others eventually recover after a symptomatic period. This study examined psychosocial factors associated with resilience and recovery from psychiatric disorders in a high-risk sample of African American adults exposed to a range of severe traumas, who participated in structured diagnostic interviews. METHOD: The sample included 259 patients exposed to at least one severe traumatic event, recruited from primary care offices at Howard University and administered the Structured Clinical Interview for DSM-IV Axis I disorders. Multinomial logistic regression was used to identify potential psychosocial factors associated with resilience and recovery, including purpose in life, mastery, and coping strategies. RESULTS: Forty-seven patients had no lifetime psychiatric disorders (resilient), 85 met criteria for at least one past DSM-IV disorder but no current disorders (recovered), and 127 met criteria for at least one current DSM-IV disorder (currently ill). The resilient group was characterized by a significantly lower lifetime trauma load. Female gender was predictive of currently ill status. In the final model, purpose in life emerged as a key factor associated with both resilience and recovery, and mastery was also significantly associated with recovery. CONCLUSIONS: The identification of psychosocial factors associated with resistance to severe trauma can inform future studies of preventive and treatment interventions for high-risk populations. Further study is needed to determine which psychosocial factors are consistently associated with resilience and to what extent they can be modified through clinical intervention.

The importance of being flexible: the ability to both enhance and suppress emotional expression predicts long-term adjustment.

Researchers have documented the consequences of both expressing and suppressing emotion using between-subjects designs. It may be argued, however, that successful adaptation depends not so much on any one regulatory process, but on the ability to flexibly enhance or suppress emotional expression in accord with situational demands. We tested this hypothesis among New York City college students in the aftermath of the September 11th terrorist attacks. Subjects' performance in a laboratory task in which they enhanced emotional expression, suppressed emotional expression, and behaved normally on different trials was examined as a prospective predictor of their adjustment across the first two years of college. Results supported the flexibility hypothesis. A regression analysis controlling for initial distress and motivation and cognitive resources found that subjects who were better able to enhance and suppress the expression of emotion evidenced less distress by the end of the second year. Memory deficits were also observed for both the enhancement and the suppression tasks, suggesting that both processes require cognitive resources.