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Quality of Life Research

, Volume 22, Issue 2, pp 231–241 | Cite as

Characteristics associated with low resilience in patients with depression and/or anxiety disorders

  • Jung-Ah Min
  • Young-Eun Jung
  • Dai-Jin Kim
  • Hyeon-Woo Yim
  • Jung-Jin Kim
  • Tae-Suk Kim
  • Chang-Uk Lee
  • Chul Lee
  • Jeong-Ho ChaeEmail author
Article

Abstract

Purpose

Despite a growing body of research on resilience and its clinical significance in depression and anxiety disorders, relatively little is known about contributing factors for resilience in patients with these illnesses. We aimed to find characteristics of patients having low resilience for elucidating its clinical implications in depression and/or anxiety disorders, primarily focused on potentially modifiable variables.

Methods

A total of 121 outpatients diagnosed with depression and/or anxiety disorders completed questionnaires measuring socio-demographic, clinical, and positive psychological factors. We divided patients into the three groups based on their Connor–Davidson resilience scale scores and investigated predictors of the low- and medium- versus high-resilience groups using multinomial logistic regression analysis.

Results

In the final regression model, low spirituality was revealed as a leading predictor of lower-resilience groups. Additionally, low purpose in life and less frequent exercise were associated with the low- and medium-resilience groups, respectively. Severe trait anxiety characterized the low- and medium-resilience groups, although it was not included in the final model.

Conclusions

Spirituality, purpose in life, and trait anxiety contribute to different levels of resilience in patients with depression and/or anxiety disorders. Our results would deepen the understanding of resilience and provide potential targets of resilience-focused intervention in these patients.

Keywords

Resilience Depression Anxiety disorder Spirituality Purpose in life Trait anxiety 

Abbreviations

PTSD

Posttraumatic stress disorder

PCCTS

Parent–child conflict tactics scales

LEC

Life events checklist

CD–RISC

Connor–Davidson resilience scale

LOT-R

Life orientation test-revised

GQ-6

Gratitude questionnaire

SHQ-6

Sense of humor questionnaire

SHS

State hope scale

FACIT–Sp

Functional assessment of chronic illness therapy–spirituality

PIL

“Purpose in life” test

BDI

Beck depression inventory

STAI

State-trait anxiety inventory

SCL-90-R

Symptom checklist 90-revised

AUDIT

Alcohol use disorder identification test

OR

Odds ratio

CI

Confidence interval

Notes

Acknowledgments

The authors wish to thank A-Young Shin and Su-Yeon Han for their assistance with data collection and management. We also thank Seung Hee Jeong for her comments on statistical analyses. This study was supported by grants from the Korea Research Foundation (2006-2005152 and 2009-0073189).

References

  1. 1.
    Bonanno, G. A., & Mancini, A. D. (2008). The human capacity to thrive in the face of potential trauma. Pediatrics, 121(2), 369–375.PubMedCrossRefGoogle Scholar
  2. 2.
    Bonanno, G. A. (2004). Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? The American Psychologist, 59(1), 20–28.PubMedCrossRefGoogle Scholar
  3. 3.
    Rutter, M. (1985). Resilience in the face of adversity: Protective factors and resistance to psychiatric disorder. British Journal of Psychiatry, 147, 598–611.PubMedCrossRefGoogle Scholar
  4. 4.
    Rutter, M. (1987). Psychosocial resilience and protective mechanisms. American Journal of Orthopsychiatry, 57(3), 316–331.PubMedCrossRefGoogle Scholar
  5. 5.
    Carver, C. S. (2005). Enhancing adaptation during treatment and the role of individual differences. Cancer, 104(11 Suppl), 2602–2607.PubMedCrossRefGoogle Scholar
  6. 6.
    Chou, L. N., & Hunter, A. (2009). Factors affecting quality of life in Taiwanese survivors of childhood cancer. Journal of Advanced Nursing, 65(10), 2131–2141.PubMedCrossRefGoogle Scholar
  7. 7.
    Alriksson-Schmidt, A. I., Wallander, J., & Biasini, F. (2007). Quality of life and resilience in adolescents with a mobility disability. Journal of Pediatric Psychology, 32(3), 370–379.PubMedCrossRefGoogle Scholar
  8. 8.
    Kennedy, P., Smithson, E., McClelland, M., Short, D., Royle, J., & Wilson, C. (2010). Life satisfaction, appraisals and functional outcomes in spinal cord-injured people living in the community. Spinal Cord, 48(2), 144–148.PubMedCrossRefGoogle Scholar
  9. 9.
    Davidson, J., Payne, V. M., Connor, K. M., Foa, E. B., Rothbaum, B. O., Hertzberg, M. A., et al. (2005). Trauma, resilience and saliostasis: Effects of treatment in post-traumatic stress disorder. International Clinical Psychopharmacology, 20(1), 43–48.PubMedCrossRefGoogle Scholar
  10. 10.
    Hoge, E. A., Austin, E. D., & Pollack, M. H. (2007). Resilience: Research evidence and conceptual considerations for posttraumatic stress disorder. Depression and Anxiety, 24(2), 139–152.PubMedCrossRefGoogle Scholar
  11. 11.
    Luthar, S. S., & Zigler, E. (1991). Vulnerability and competence: A review of research on resilience in childhood. American Journal of Orthopsychiatry, 61(1), 6–22.PubMedCrossRefGoogle Scholar
  12. 12.
    Ai, A. L., Cascio, T., Santangelo, L. K., & Evans-Campbell, T. (2005). Hope, meaning, and growth following the September 11, 2001, terrorist attacks. Journal of Interpersonal Violence, 20(5), 523–548.PubMedCrossRefGoogle Scholar
  13. 13.
    Garmezy, N. (1993). Children in poverty: Resilience despite risk. Psychiatry, 56(1), 127–136.PubMedGoogle Scholar
  14. 14.
    Campbell-Sills, L., Forde, D. R., & Stein, M. B. (2009). Demographic and childhood environmental predictors of resilience in a community sample. Journal of Psychiatric Research, 43(12), 1007–1012.PubMedCrossRefGoogle Scholar
  15. 15.
    Barskova, T., & Oesterreich, R. (2009). Post-traumatic growth in people living with a serious medical condition and its relations to physical and mental health: A systematic review. Disability and Rehabilitation, 31(21), 1709–1733.PubMedCrossRefGoogle Scholar
  16. 16.
    Southwick, S. M., Vythilingam, M., & Charney, D. S. (2005). The psychobiology of depression and resilience to stress: Implications for prevention and treatment. Annual Review of Clinical Psychology, 1, 255–291.PubMedCrossRefGoogle Scholar
  17. 17.
    Gibb, B. E., Chelminski, I., & Zimmerman, M. (2007). Childhood emotional, physical, and sexual abuse, and diagnoses of depressive and anxiety disorders in adult psychiatric outpatients. Depression and Anxiety, 24(4), 256–263.PubMedCrossRefGoogle Scholar
  18. 18.
    van der Kolk, B. A., Pelcovitz, D., Roth, S., Mandel, F. S., McFarlane, A., & Herman, J. L. (1996). Dissociation, somatization, and affect dysregulation: The complexity of adaptation of trauma. The American Journal of Psychiatry, 153(7 Suppl), 83–93.PubMedGoogle Scholar
  19. 19.
    MacMillan, H. L., Fleming, J. E., Streiner, D. L., Lin, E., Boyle, M. H., Jamieson, E., et al. (2001). Childhood abuse and lifetime psychopathology in a community sample. The American Journal of Psychiatry, 158(11), 1878–1883.PubMedCrossRefGoogle Scholar
  20. 20.
    Lecrubier, Y. (2001). The burden of depression and anxiety in general medicine. Journal of Clinical Psychiatry, 62(Suppl 8), 4–9; discussion 10–11.PubMedGoogle Scholar
  21. 21.
    Hjemdal, O., Vogel, P. A., Solem, S., Hagen, K., & Stiles, T. C. (2011). The relationship between resilience and levels of anxiety, depression, and obsessive-compulsive symptoms in adolescents. Clinical Psychology and Psychotherapy, 18(4), 314–321.PubMedCrossRefGoogle Scholar
  22. 22.
    Burton, N. W., Pakenham, K. I., & Brown, W. J. (2009). Evaluating the effectiveness of psychosocial resilience training for heart health, and the added value of promoting physical activity: A cluster randomized trial of the READY program. BMC Public Health, 9, 427.PubMedCrossRefGoogle Scholar
  23. 23.
    Connor, K. M., & Zhang, W. (2006). Recent advances in the understanding and treatment of anxiety disorders. Resilience: Determinants, measurement, and treatment responsiveness. CNS Spectrum, 11(10 Suppl 12), 5–12.Google Scholar
  24. 24.
    Fava, G. A., & Tomba, E. (2009). Increasing psychological well-being and resilience by psychotherapeutic methods. Journal of Personality, 77(6), 1903–1934.PubMedCrossRefGoogle Scholar
  25. 25.
    Alim, T. N., Feder, A., Graves, R. E., Wang, Y., Weaver, J., Westphal, M., et al. (2008). Trauma, resilience, and recovery in a high-risk African-American population. The American Journal of Psychiatry, 165(12), 1566–1575.PubMedCrossRefGoogle Scholar
  26. 26.
    Ingram, R. E., & Price, J. M. (2001). The role of vulnerability in understanding psychopathology. In R. E. Ingram & J. M. Price (Eds.), Vulnerability to psychopathology: Risk across the lifespan (pp. 3–19). New York: The Guilford Press.Google Scholar
  27. 27.
    Davidson, J. R., Payne, V. M., Connor, K. M., Foa, E. B., Rothbaum, B. O., Hertzberg, M. A., et al. (2005). Trauma, resilience and saliostasis: Effects of treatment in post-traumatic stress disorder. International Clinical Psychopharmacology, 20(1), 43–48.PubMedCrossRefGoogle Scholar
  28. 28.
    Davidson, J., Watkins, L., Owens, M., Krulewicz, S., Connor, K., Carpenter, D., et al. (2005). Effects of paroxetine and venlafaxine XR on heart rate variability in depression. Journal of Clinical Psychopharmacology, 25(5), 480–484.PubMedCrossRefGoogle Scholar
  29. 29.
    Muller-Spahn, F. (2008). Individualized preventive psychiatry: Syndrome and vulnerability diagnostics. European Archives of Psychiatry and Clinical Neuroscience, 258(Suppl 5), 92–97.PubMedCrossRefGoogle Scholar
  30. 30.
    Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The mini-international neuropsychiatric interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl 20), 22–33; quiz 34–57.PubMedGoogle Scholar
  31. 31.
    Bonanno, G. A., Galea, S., Bucciarelli, A., & Vlahov, D. (2007). What predicts psychological resilience after disaster? The role of demographics, resources, and life stress. Journal of Consulting and Clinical Psychology, 75(5), 671–682.PubMedCrossRefGoogle Scholar
  32. 32.
    Straus, M. A., Hamby, S. L., Finkelhor, D., Moore, D. W., & Runyan, D. (1998). Identification of child maltreatment with the parent–child conflict tactics scales: Development and psychometric data for a national sample of American parents. Child Abuse & Neglect, 22(4), 249–270.CrossRefGoogle Scholar
  33. 33.
    Gray, M. J., Litz, B. T., Hsu, J. L., & Lombardo, T. W. (2004). Psychometric properties of the life events checklist. Assessment, 11(4), 330–341.PubMedCrossRefGoogle Scholar
  34. 34.
    Bae, H., Kim, D., Koh, H., Kim, Y., & Park, J. S. (2008). Psychometric properties of the life events checklist-Korean version. Psychiatry Investigation, 5(3), 163–167.PubMedCrossRefGoogle Scholar
  35. 35.
    Oh, H. J. (2004). Effect of childhood abuse and exposure to parental violence on problem in drinking in later life. Seoul: School of Social Welfare, Yonsei University.Google Scholar
  36. 36.
    Lee, Y. J. (1995). The relationship between stress, social support, self respect, depression, and anxiety. Seoul: School of Educational Psychology, Seoul Women’s University.Google Scholar
  37. 37.
    Baek, H. S., Lee, K. U., Joo, E. J., Lee, M. Y., & Choi, K. S. (2010). Reliability and validity of the Korean version of the Connor–Davidson resilience scale. Psychiatry Investigation, 7(2), 109–115.PubMedCrossRefGoogle Scholar
  38. 38.
    Connor, K. M., & Davidson, J. R. (2003). Development of a new resilience scale: The Connor–Davidson resilience scale (CD–RISC). Depression and Anxiety, 18(2), 76–82.PubMedCrossRefGoogle Scholar
  39. 39.
    Windle, G., Bennett, K. M., & Noyes, J. (2011). A methodological review of resilience measurement scales. Health and Quality of Life Outcomes, 9, 8.PubMedCrossRefGoogle Scholar
  40. 40.
    Davidson, J. R., Baldwin, D. S., Stein, D. J., Pedersen, R., Ahmed, S., Musgnung, J., et al. (2008). Effects of venlafaxine extended release on resilience in posttraumatic stress disorder: An item analysis of the Connor–Davidson resilience scale. International Clinical Psychopharmacology, 23(5), 299–303.PubMedCrossRefGoogle Scholar
  41. 41.
    Scheier, M. F., Carver, C. S., & Bridges, M. W. (1994). Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A reevaluation of the life orientation test. Journal of Personality and Social Psychology, 67(6), 1063–1078.PubMedCrossRefGoogle Scholar
  42. 42.
    McCullough, M. E., Emmons, R. A., & Tsang, J. A. (2002). The grateful disposition: A conceptual and empirical topography. Journal of Personality and Social Psychology, 82(1), 112–127.PubMedCrossRefGoogle Scholar
  43. 43.
    Svebak, S. (1996). The development of the sense of humor questionnaire: From SHQ to SHQ-6. Humor: International Journal of Humor Research, 9, 341–361.CrossRefGoogle Scholar
  44. 44.
    Snyder, C. R., Sympson, S. C., Ybasco, F. C., Borders, T. F., Babyak, M. A., & Higgins, R. L. (1996). Development and validation of the state hope scale. Journal of Personality and Social Psychology, 70(2), 321–335.PubMedCrossRefGoogle Scholar
  45. 45.
    Peterman, A. H., Fitchett, G., Brady, M. J., Hernandez, L., & Cella, D. (2002). Measuring spiritual well-being in people with cancer: The functional assessment of chronic illness therapy–spiritual well-being scale (FACIT–Sp). Annuls of Behavioral Medicine, 24(1), 49–58.CrossRefGoogle Scholar
  46. 46.
    Crumbaugh, J. C., & Maholick, L. T. (1964). An experimental study in existentialism: The psychometric approach to Frankl’s concept of neogenic neurosis. Journal of Clinical Psychology, 20, 200–207.PubMedCrossRefGoogle Scholar
  47. 47.
    Shin, H., Lyu, J., & Lee, M. (2005). Testing the one-factor and two-factor models of optimism and pessimism in Korean adolescents. Korean Journal of School Psychology, 2(1), 79–97.Google Scholar
  48. 48.
    Huang, M. (1992). The relationship between the sense of humor and ways of stress coping. Iksan: Educational Research, Wonkwang University.Google Scholar
  49. 49.
    Cho, H. (2010). The effects of hope on life stress, psychopathology and life satisfaction. Korean Journal of Clinical Psychology, 29(3), 839–852.Google Scholar
  50. 50.
    Shin, H. S. (2002). Effects on depressive disposition of middle-aged women by style of living. Korean Journal of Women Psychology, 7(1), 29–45.Google Scholar
  51. 51.
    Kwon, S. J., Kim, K. H., & Lee, H. S. (2006). Validation of the Korean version of gratitude questionnaire. Korean Journal of Health Psychology, 2006(1), 177–190.Google Scholar
  52. 52.
    Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571.PubMedCrossRefGoogle Scholar
  53. 53.
    Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press.Google Scholar
  54. 54.
    Derogatis, L. R. (1977). Symptom checklist-90-revised (SCL-90-R) manual I. Baltimore: Clinical Psychometric Research Unit, Johns Hopkins University.Google Scholar
  55. 55.
    Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction, 88(6), 791–804.PubMedCrossRefGoogle Scholar
  56. 56.
    Rhee, M., Lee, Y., Jung, H., Choi, J., Kim, S., Kim, Y., et al. (1995). A standardization study of beck depression inventory II—Korean version (K-BDI): Validity. Korean Journal of Psychopathology, 4(1), 96–104.Google Scholar
  57. 57.
    Hahn, D. W., Lee, C. H., & Chon, K. K. (1996). Korean adaptation of Spielberger’s STAI (K-STAI). Korean Journal of Health Psychology, 1(1), 1–14.CrossRefGoogle Scholar
  58. 58.
    Kim, K. I., Won, H. T., Lee, J. H., & Kim, K. Y. (1978). Standardization study of symptom check list-90 in Korea I: Characteristics of normal responses. Journal of Korean Neuropsychiatric Association, 17, 449–458.Google Scholar
  59. 59.
    Kim, J. S., Oh, M. K., Park, B. K., Lee, M. K., & Kim, G. J. (1999). Screening criteria of alcoholism by alcohol use disorders identification test (AUDIT) in Korea. Journal of Korean Academy of Family Medicine, 20(9), 1152–1159.Google Scholar
  60. 60.
    Wingo, A. P., Wrenn, G., Pelletier, T., Gutman, A. R., Bradley, B., & Ressler, K. J. (2010). Moderating effects of resilience on depression in individuals with a history of childhood abuse or trauma exposure. Journal of Affective Disorders, 126(3), 411–414.PubMedCrossRefGoogle Scholar
  61. 61.
    Seligman, M. E., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. The American Psychologist, 55(1), 5–14.PubMedCrossRefGoogle Scholar
  62. 62.
    Chida, Y., & Steptoe, A. (2008). Positive psychological well-being and mortality: A quantitative review of prospective observational studies. Psychosomatic Medicine, 70(7), 741–756.PubMedCrossRefGoogle Scholar
  63. 63.
    Muldoon, M., & King, N. (1995). Spirituality, health care, and bioethics. Journal of Religion and Health, 34(4), 329–349.PubMedCrossRefGoogle Scholar
  64. 64.
    Frankl, V. E. (1966). Logotherapy and existential analysis—A review. The American Journal of Psychotherapy, 20(2), 252–260.Google Scholar
  65. 65.
    Winter, U., Hauri, D., Huber, S., Jenewein, J., Schnyder, U., & Kraemer, B. (2009). The psychological outcome of religious coping with stressful life events in a Swiss sample of church attendees. Psychotherapy and Psychosomatics, 78(4), 240–244.PubMedCrossRefGoogle Scholar
  66. 66.
    Dew, R. E., Daniel, S. S., Goldston, D. B., McCall, W. V., Kuchibhatla, M., Schleifer, C., et al. (2010). A prospective study of religion/spirituality and depressive symptoms among adolescent psychiatric patients. Journal of Affective Disorders, 120(1–3), 149–157.PubMedCrossRefGoogle Scholar
  67. 67.
    Nelson, C. J., Rosenfeld, B., Breitbart, W., & Galietta, M. (2002). Spirituality, religion, and depression in the terminally ill. Psychosomatics, 43(3), 213–220.PubMedCrossRefGoogle Scholar
  68. 68.
    McClain, C. S., Rosenfeld, B., & Breitbart, W. (2003). Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients. Lancet, 361(9369), 1603–1607.PubMedCrossRefGoogle Scholar
  69. 69.
    Ryff, C. D., Dienberg, L. G., Urry, H. L., Muller, D., Rosenkranz, M. A., Friedman, E. M., et al. (2006). Psychological well-being and ill-being: Do they have distinct or mirrored biological correlates? Psychotherapy and Psychosomatics, 75(2), 85–95.PubMedCrossRefGoogle Scholar
  70. 70.
    Boyle, P. A., Barnes, L. L., Buchman, A. S., & Bennett, D. A. (2009). Purpose in life is associated with mortality among community-dwelling older persons. Psychosomatic Medicine, 71(5), 574–579.PubMedCrossRefGoogle Scholar
  71. 71.
    Borg, J., Andree, B., Soderstrom, H., & Farde, L. (2003). The serotonin system and spiritual experiences. The American Journal of Psychiatry, 160(11), 1965–1969.PubMedCrossRefGoogle Scholar
  72. 72.
    Ryff, C. D., Singer, B. H., & Dienberg, L. G. (2004). Positive health: Connecting well-being with biology. Philosophical Transactions of the Royal Society of London, Series B, Biological Science, 359(1449), 1383–1394.CrossRefGoogle Scholar
  73. 73.
    Henry, M., Cohen, S. R., Lee, V., Sauthier, P., Provencher, D., Drouin, P., et al. (2010). The meaning–making intervention (MMI) appears to increase meaning in life in advanced ovarian cancer: A randomized controlled pilot study. Psychooncology, 19(12), 1340–1347.PubMedCrossRefGoogle Scholar
  74. 74.
    Hjemdal, O., Aune, T., Reinfjell, T., Stiles, T. C., & Friborg, O. (2007). Resilience as a predictor of depressive symptoms: A correlational study with young adolescents. Clinical Child Psychology and Psychiatry, 12(1), 91–104.PubMedCrossRefGoogle Scholar
  75. 75.
    Sexton, M. B., Byrd, M. R., & von Kluge, S. (2010). Measuring resilience in women experiencing infertility using the CD–RISC: Examining infertility-related stress, general distress, and coping styles. Journal of Psychiatric Research, 44(4), 236–241.PubMedCrossRefGoogle Scholar
  76. 76.
    Campbell-Sills, L., Cohan, S. L., & Stein, M. B. (2006). Relationship of resilience to personality, coping, and psychiatric symptoms in young adults. Behavior Research and Therapy, 44(4), 585–599.CrossRefGoogle Scholar
  77. 77.
    Sandi, C., & Richter-Levin, G. (2009). From high anxiety trait to depression: A neurocognitive hypothesis. Trends in Neuroscience, 32(6), 312–320.CrossRefGoogle Scholar
  78. 78.
    Hariri, A. R. (2009). The neurobiology of individual differences in complex behavioral traits. Annual Review of Neuroscience, 32, 225–247.PubMedCrossRefGoogle Scholar
  79. 79.
    Charney, D. S. (2004). Psychobiological mechanisms of resilience and vulnerability: Implications for successful adaptation to extreme stress. The American Journal of Psychiatry, 161(2), 195–216.PubMedCrossRefGoogle Scholar
  80. 80.
    Hyde, L. W., Gorka, A., Manuck, S. B., & Hariri, A. R. (2011). Perceived social support moderates the link between threat-related amygdala reactivity and trait anxiety. Neuropsychologia, 49(4), 651–656.PubMedCrossRefGoogle Scholar
  81. 81.
    Sartori, S. B., Hauschild, M., Bunck, M., Gaburro, S., Landgraf, R., & Singewald, N. (2011). Enhanced fear expression in a psychopathological mouse model of trait anxiety: Pharmacological interventions. PLoS ONE, 6(2), e16849.PubMedCrossRefGoogle Scholar
  82. 82.
    Salmon, P. (2001). Effects of physical exercise on anxiety, depression, and sensitivity to stress: A unifying theory. Clinical Psychology Review, 21(1), 33–61.PubMedCrossRefGoogle Scholar
  83. 83.
    Yu, X. N., Lau, J. T., Mak, W. W., Zhang, J., & Lui, W. W. (2011). Factor structure and psychometric properties of the Connor–Davidson resilience scale among Chinese adolescents. Comprehensive Psychiatry, 52(2), 218–224.PubMedCrossRefGoogle Scholar
  84. 84.
    Karairmak, O. (2010). Establishing the psychometric qualities of the Connor–Davidson resilience scale (CD–RISC) using exploratory and confirmatory factor analysis in a trauma survivor sample. Psychiatry Research, 179(3), 350–356.PubMedCrossRefGoogle Scholar
  85. 85.
    Lee, J. W., Jones, P. S., Mineyama, Y., & Zhang, X. E. (2002). Cultural differences in responses to a Likert scale. Research in Nursing & Health, 25(4), 295–306.CrossRefGoogle Scholar
  86. 86.
    Andrews, G. (1996). Comorbidity and the general neurotic syndrome. British Journal of Psychiatry, 30, 76–84.Google Scholar
  87. 87.
    Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Towards a unified treatment for emotional disorders. Behavior Therapy, 35, 205–230.CrossRefGoogle Scholar
  88. 88.
    Ehrenreich, J. T., Goldstein, C. M., Wright, L. R., & Barlow, D. H. (2009). Development of a unified protocol for the treatment of emotional disorders in youth. Child & Family Behavior Therapy, 31(1), 20–37.CrossRefGoogle Scholar
  89. 89.
    Rutter, M. (2006). Implications of resilience concepts for scientific understanding. Annals of the New York Academy of Science, 1094, 1–12.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2012

Authors and Affiliations

  • Jung-Ah Min
    • 1
  • Young-Eun Jung
    • 2
  • Dai-Jin Kim
    • 1
  • Hyeon-Woo Yim
    • 3
  • Jung-Jin Kim
    • 1
  • Tae-Suk Kim
    • 1
  • Chang-Uk Lee
    • 1
  • Chul Lee
    • 1
  • Jeong-Ho Chae
    • 1
    Email author
  1. 1.Department of Psychiatry, Seoul St. Mary’s HospitalThe Catholic University of Korea, College of MedicineSeoulRepublic of Korea
  2. 2.Department of PsychiatrySt. Carollo HospitalSuncheonRepublic of Korea
  3. 3.Department of Preventive MedicineThe Catholic University of Korea, College of MedicineSeoulRepublic of Korea

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