A Modified CD-RISC 11 A Modified CD-RISC : Including Previously Unaccounted for Resilience Variables

Background. Resilience is considered as the capacity to overcome adversity. Identifying psychiatric patients with lower resilience scores may assist mental health or other healthcare professionals in tailoring treatment to patients’ needs. The original 25-item Connor-Davidson Resilience Scale (CD-RISC) has been used widely to measure resilience. However, the factor structure of CD-RISC in the original paper has not been replicated in subsequent studies. We sought to modify the original 25-item CD-RISC to achieve a stable factor structure. Methods. The original 25-item CD-RISC was modified to include three new items, and most original items were revised for clarity and relevance for respondents, to achieve a more precise and accurate response. A few items were deleted based on empirically driven modifications. A total of 266 respondents were obtained from a university-based psychiatric outpatient clinic and hospital psychiatric outpatient clinic. An exploratory factor analysis was conducted. Results. A four-dimension factor structure was identified using this data set. One item, “have to act on hunch” was deleted from the factor analysis due to weak correlation with the other variables. The instrument had excellent internal consistency (Cronbach’s Alpha = 0.94). Conclusions. The modified 27-item CD-RISC achieved a stable factor structure and high internal consistency, and generated a more interpretable result than the original CD-RISC. KS J Med 2013; 6(1):11-20. Introduction Resilience is the ability to overcome adversity and to return to a person’s previously established functional baseline. The concept of resilience has been studied among different subsets of people, including the general population, the elderly, soldiers returning from active military duty overseas, and individuals who, due to their line of work, are predisposed to posttraumatic stress disorder (PTSD) and/or other mental illnesses. The scope of what has been included in the term “resilience” has adapted as increased interest in the subject spurred research in various subject populations. Initially, resilience was defined as the ability to cope, and it often was used interchangeably with hardiness. Maddi and Khoshaba defined hardiness as a measure of mental health, however, they did not take into account dimensions beyond psychological. Richardson proposed a biopsychospiritual model (encompassing mind, body, soul, and current life events), whereas Connor and Davidson proposed a more biopsychosocial model (including trust in one's instincts, control, spiritual influences, and personal competency). The definition of resilience has evolved to encompass flexibility, positive adaptKansas Journal of Medicine 2013 A Modified CD-RISC 12 ation, the ability to thrive in the face of adversity, and the ability to maintain function during stressful events. Resilience is considered a multi-dimensional concept that varies among people and is influenced by characteristics such as gender, ethnic background, cultural background, and educational level. Resilience has a strong and direct impact on patient health. A high level of resilience is protective against mental illnesses such as depression and PTSD, as well as physical illness, and is associated closely with an individual’s overall well-being. Additionally, a definitive correlation has been made between increasing levels of resilience and an individual’s ability to use learned skills to alter his or her environment, or perception thereof, to attain a higher level of functioning. With this application in mind, measures have been taken to develop self-reported resilience scales with the goal of identifying individuals with lower than average scores and who, as such, may be at increased risk of negative health outcomes. The implication is that these individuals could be identified and targeted resiliencebuilding strategies could be developed and implemented accordingly. CD-RISC. In 2003, Connor and Davidson published a resilience scale, “Connor Davidson Resilience Scale” (CDRISC). Items included in the scale were selected through a search of resilience literature. The CD-RISC survey is comprised of 25 items that were deemed to be components of resilience. A higher score suggested an individual was more resilient. To validate the scale, Connor and Davidson distributed it to five populations: a non-helpseeking general population, primary care outpatients, psychiatric outpatients in private practice, participants in a study of generalized anxiety disorder, and participants in two PTSD clinical trials. Other studies of cross-cultural validity and factor analysis. The CD-RISC has been used and validated across several groups, including South African and Chinese adolescents, Korean students, firefighters, nurses, and Indian students. In addition to being validated across various groups, these studies also looked at factor structure of the 25-item resilience survey. Though the studies conducted among Chinese adolescents and Korean students found that the five-factor model of the original CD-RISC was reproducible, studies conducted in India, South Africa, Australia, and the United States did not concur. The evaluation among Indian students confirmed four factors: hardiness, optimism, resourcefulness, and purpose. Jorgensen and Seedat were unable to reproduce the original factor structure using a sample of 701 South African adolescents, however, they identified three factors in their study: tenacity, adaptation, and spirituality. In two studies, the original 25-item CDRISC five-factor model was shown to be unstable. In 2007, Campbell-Sills and Stein inquired about the composition of the original CD-RISC. They found, via factor analysis, that the 25-item scale was not stable over two identical populations. Thus, they comprised a 10-item abbreviated version of the CD-RISC and established strong psychometric factors structuring the new format. In this study, hardiness and persistence were identified initially as two stable factors, and further manipulation allowed for the formation of a unidimensional factor. Burns and Anstey confirmed the uni-dimensional measure of the original CD-RISC. Furthermore, Vaishnavi et al. comprised a CD-RISC 2 scale that was made up of only two items from the original 25-item scale: “Able to adapt to change,” and “Tend to bounce back after hardship or illness” to reflect the meaning of resilience. Kansas Journal of Medicine 2013 A Modified CD-RISC 13 Purpose. As the concept of resilience is studied further and understood, it is important to incorporate factors that influence resilience into these existing instruments. It is also important to relate the questions to participants directly, so that the participant may answer appropriately and precisely. In this study, we proposed modifications to the original 25-item CDRISC such as the use of first-person verbiage and the addition of items that were neglected in the original CD-RISC. Methods Instrument. The instrument, a modified version of the original 25-item CD-RISC, was designed to measure resilience. Three new items were added to the original 25item instrument, which take into account aspects that are associated with resilience but were neglected in the original CD-RISC. Two items, "My family is willing to help me make decisions and listen to me" and "My friends are willing to help me make decisions and listen to me" were added to the modified scale to address the perceived support from family and friends. This was relevant as a higher level of social support is associated with increased resilience. The question "I find my job rewarding” was added to the modified scale to assess job satisfaction, which symbolizes purpose and balance, both of which are associated with increased resilience. Additionally, “Coping with stress strengthens" and "In control of your life" in the original 25-item CD-RISC were removed, and replaced with "I feel obligated to assist others in need", and "I have few regrets in life", respectively. The feeling of assisting others in need is tied to the feeling of having purpose and meaning in life, both of which are factors associated with resilience not represented in the original CD-RISC. Having few regrets in life is tied to problem-solving, another factor tied to resilience. The benefit of the two items we added outweighed the benefit of the old items. The two old items (“coping with stress strengthens” and “in control of your life”) were ambiguous. Several of the original items were reworded so that the modified statements were all presented in the first person (Table 1). This change in verbiage prompted readers to identify themselves as active participants in the various items. For example, we reworded one item from "Able to adapt to change," to "I am able to adapt to change," allowing the reader to understand that she/he is intended to be the subject performing the action. Like the original CD-RISC, the modified CD-RISC is a self-reporting scale in a Likert-type fashion. Each item was rated from "not true at all" (1 point) to "true nearly all the time" (5 points). The total number of points in the modified survey was 135. No identifiers were collected to ensure subject confidentiality. Participants. In the original 25-item CDRISC study, the total number of participants (inclusive of all five populations) was 828; 577 patients were from the general population, 139 were from primary care, 43 were psychiatric outpatients in private practice, 25 were from a study of generalized anxiety disorder, and 44 were from two clinical trials of posttraumatic stress disorder (PTSD). This investigation studied general outpatient psychiatry patients recognizing that the participants of general outpatient psychiatry clinics comprised 5% of those in the original study. The current study increased the desired subject number to 266 to increase power. To mirror the original Connor and Davidson’s methodology, the modified CDRISC was d