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Comprehensive Psychiatry 69 (2016) 88 – 99
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Patients' resilience and distress over time: Is resilience a prognostic

indicator of treatment?
Vilmantė Pakalniškienė a,⁎, Rima Viliūnienė b , Jan Hilbig b
a
Department of General Psychology, Vilnius University, Lithuania
b
Clinic of Psychiatry, Vilnius University, Lithuania

Abstract

Background: Resilience is a positive adaptation or the ability to maintain mental health despite experiencing difficulty. Many researchers are
linking resilience with many aspects of life, most often with better mental health. Resilience can affect health status and symptoms, but
conversely, it can also be affected by health status or symptoms. From the literature it appears that resilience can even be a predictor of
psychiatric symptoms. Resilience can predict severity of symptoms, but the question is whether symptoms can also affect resilience over time
when previous levels of resilience are controlled for. The aim of this study was to explore the relationship of resilience scores and the
expression of distress in the context of treatment over time.
Methods: Ninety-five patients diagnosed with affective and anxiety disorders from a clinical sample treated psychotherapeutically with
(N = 81) or without (N = 14) a pharmacological treatment at a psychotherapy day center participated in the study. All the participants were
assessed three times: at the beginning of the treatment, after treatment (after 6 weeks), and after a follow-up interval of 6 months after the end
of therapy. The Resilience Scale for Adults and the Clinical Outcomes in Routine Evaluation Outcome Measure were used in the study.
Results: All distress indicators were expressed more before the treatment compared to right after the treatment or half a year after the
treatment. Distress indicators were more stable from Time 1 to Time 2, while from Time 2 to Time 3 they were less stable. In this study,
resilience increased during the treatment and stayed stable after the treatment. Looking at bidirectional relationships between distress
indicators and resilience over time, the results of this study suggest that levels of resilience have a prognostic value for the reduction of
symptoms over the course of treatment. However, decrease in distress does not predict increase in resilience.
Conclusions: Levels of resilience measured by RSA scores seem to have a certain prognostic value for the reduction of symptoms over the
course of treatment. Perception of self was the strongest predictor of lower levels of distress over time when distress and perception of self-
stability are controlled for. Results suggest that decreased distress indicators are not directly related to increasing resilience over six weeks or
over six months. Considering that resilience is rather stable over time and indicators are less stable, it is possible that resilience could be
increased by personal or environmental factors, and a decrease in distress is not a contributing factor. In this study distress decreased over
time, while resilience characteristics increased for the whole sample. Patients in this study underwent treatment, and decreases in global
distress were a result of treatment. An increase in resilience over time supports the effectiveness of treatment. However, there were no
significant differences between treatment types while evaluating models. Results suggest that treatments (psychotherapy or
psychopharmacological with psychotherapy) were equally effective for the chosen patients.
© 2016 Elsevier Inc. All rights reserved.

1. Introduction (PTSD); why others develop moderate psychological

Why are some people more prone to experiencing stress
while others are less prone to it? Why some people develop
psychiatric symptoms and disorders, such as anxiety,
insomnia, depression or even posttraumatic stress disorder
⁎ Corresponding author at: Department of General Psychology, Vilnius
University, Universiteto 9/1, 01513 Vilnius, Lithuania. Tel.:+370 610 70375.
E-mail address: vilmante.pakalniskiene@fsf.vu.lt (V. Pakalniškienė).
http://dx.doi.org/10.1016/j.comppsych.2016.05.010
0010-440X/© 2016 Elsevier Inc. All rights reserved.
symptoms; still others report no psychological symptoms
in response to stress? The answer could lie in their level of
resilience. Essentially, resilience refers to a positive
adaptation or the ability to maintain mental health despite
experiencing difficulty [1]. Resilience refers to the capacity
of an individual to avoid negative social, psychological and
biological consequences of extreme stress that would
otherwise compromise their psychological or physical
well-being. Recent reports indicate that resilience in humans
 V. Pakalniškienė et al. / Comprehensive Psychiatry 69 (2016) 88–99
represents an active, adaptive process and not simply the
absence of pathological responses that occur in more
susceptible individuals [2,3]. Resilience refers to a dynamic
process encompassing positive adaptation within the context
of significant adversity. Implicit within this notion are two
critical conditions: (1) exposure to significant threat or
severe adversity; and (2) the achievement of positive
adaptation despite major assaults on the developmental
process [4]. Resilience describes the ability to thrive in the face
of adversity or to bounce back from challenges or setbacks,
and is one of several factors that can influence how individuals
respond to stress [5]. Thus, resilience — the ability of most
people, when exposed even to extraordinary levels of stress
and trauma, to maintain normal psychological and physical
functioning and avoid serious mental illness [6].
Studies on resilience are expanding rapidly. Resilience is
studied by researchers from diverse disciplines, including
psychology, psychiatry, sociology, and others disciplines.
Various sources of resilience are mentioned in the literature.
One of these sources is personal factors. The findings in the
literature indicate that intellectual functioning, cognitive
flexibility, social attachment, positive self-concepts, emo-
tional regulation, positive emotions, spirituality, active
coping, hardiness, optimism, hope, resourcefulness, and
adaptability are associated with resilience [7]. Psychosocial
factors associated with depression and/or stress resilience
include positive emotions and optimism, humor, cognitive
flexibility, cognitive explanatory style and reappraisal,
acceptance, religion/spirituality, altruism, social support,
role models, coping style, exercise, capacity to recover from
negative events, and stress inoculation [8]. In addition to
personal factors are biological and environmental factors.
Biological factors refer to brain structure, functioning,
neurobiological systems, hormones, and neurotransmitters
[9]. Neurobiological factors that are discussed and contrasted
include serotonin, the 5-HT1A receptor, polymorphisms of
the 5-HT transporter gene, norepinephrine, alpha-2 adrener-
gic receptors, neuropeptide Y, polymorphisms of the alpha-2
adrenergic gene, dopamine, corticotropin-releasing hormone
(CRH), dehydroepiandrosterone (DHEA), cortisol, and CRH
receptors. These factors are described in the context of brain
regions believed to be involved in stress, depression, and
resilience to stress [8]. Recent research has begun to identify
the environmental, genetic, epigenetic and neural mecha-
nisms that underlie resilience, and has shown that resilience
is mediated by adaptive changes in several neural circuits
involving numerous neurotransmitter and molecular path-
ways. These changes shape the functioning of the neural
circuits that regulate reward, fear, emotion reactivity and
social behavior, which together are thought to mediate
successful coping with stress [3]. Eleven possible neuro-
chemical, neuropeptide, and hormonal mediators of the
psychobiological response to extreme stress were identified
and related to resilience or vulnerability. The neural
mechanisms of reward and motivation (hedonia, optimism,
and learned helpfulness), fear responsiveness (effective
89
behaviors despite fear), and adaptive social behavior
(altruism, bonding, and teamwork) were found to be relevant
to the character traits associated with resilience [2].
Environmental factors include social support, relationships
with family and peers, good parenting skills, community
factors, cultural factors, spirituality, religion, etc. [3]. Hence,
there are many sources of resilience, which often interact,
and it may be hard to make a clear distinction between them. It
is understandable that it is harder to change some sources of
resilience, for example biological factors; however, environ-
mental factors might be corrected easier over a lifetime.
Many researchers are linking resilience with many aspects
in life, but most often with better mental health. It has been
found that resilience negatively relates to anxiousness,
depressed mood, and suicidal intentions [10]. Resilience has
also been found to maintain a significant relationship with
physical health. Resilience is positively associated with better
physical health for women that are undergoing treatment as
well as better recovery tendencies [11]. Resilience relates not
only to health, but also to the ability to cope with the stress that
affects our health. Thus, resilience seems to be a protective
factor. Resilience may be one of the key protective factors
against depression and other mental disorders [12].
Some researchers indicate that protective aspects of
resilience can be grouped into three categories that may
overlap: positive personal dispositions, family coherence,
and social resources outside the family [13]. Thus, it appears
that personal or environmental dispositions could be a source
for resilience as well as a resilience-protective resource.
Likewise, resilience can affect these dispositions, but it can
also be affected by these dispositions. Resilience can affect
health status and symptoms, but conversely it can also be
affected by health status or symptoms.
What does the existing literature suggest about these
affects? Hjemdal et al. [12] looked the first time at how a
self-report scale for adult resilience could predict the
development of psychiatric symptoms. In this study the
authors sought to determine whether healthy subjects with a
high level of resilience would experience fewer psychiatric
symptoms when faced with stressful life events, as compared
with healthy subjects with lower resilience rates. They found
that individuals who reported higher scores on the resilience
scale were essentially unchanged regarding the number of
psychiatric symptoms when exposed to stressful life events.
The authors suggested that this finding indicates that these
events did not negatively impact individuals who had more
protective resources available. However, individuals who
reported lower levels of resilience developed higher numbers
of psychiatric symptoms at follow-up when exposed to
stressful life events. On the other hand, more psychiatric
symptoms manifested after stressful events for subjects with
lower scores on the resilience scale [14]. Higher expression
of protective resilience factors has been found to indicate
lower expression of psychological symptoms and, to a
certain extent, the absence of psychopathology [12,15,16].
These results were applied to the total RSA (Resilience Scale
90 V. Pakalniškienė et al. / Comprehensive Psychiatry 69 (2016) 88–99
for Adults) score, and the RSA-social competence and
RSA-planned future factors. These findings which are
described in detail later remained significant even when
controlling for gender, age, and psychiatric symptoms at
pre-test and for the number of life events. The authors used
the RSA measure, suggesting that the RSA measure reflects
three measurement domains for resilience-protective re-
sources: positive personal dispositions, family coherence,
and social resources outside the family. Thus, it seems that
resilience can be a predictor for psychiatric symptoms.
Consequently, resilience could predict the severity of
symptoms, but the question if symptoms could also affect
resilience over time if previous levels of resilience are
controlled for is not answered in the existing literature.
Over the past 20 years, research has shown that resilience
is a multi-dimensional feature, which varies depending on
the situation, time, age, gender, cultural background,
personality, and a variety of life circumstances [17–21].
Resilience may decrease or increase over a lifetime. Each
person, depending on their life experiences, can have a
different level of resilience [22]. Research has shown that
psychological resilience may be increased by positive
experiences and older age. For example, positive interper-
sonal relationships can help reduce the negative conse-
quences of past experiences [23]. Differences in male and
female resilience have not often been studied. However there
is evidence that women tend to receive and provide more
social support [24].
There are some general gender differences found in larger
samples, where females report more social and interpersonal
resources compared with males, and males rate themselves
higher on personal dispositions than females [12,24].
Women have been shown to have lower self-confidence,
lower self-esteem, and lower self-efficacy compared to men
[25–28]. Women may be less resilient to stressors involving
friends and family due to their social roles as caregivers
[29,30].
In this study we chose to evaluate the resilience of
patients who received treatment, and we relied on other
researchers' data that showed resilience may be an important
target in the treatment of depression, anxiety, and stress
responses [31–34]. Resilience is related to overall health
status. People with mental disorders should have lower levels
of resilience than the rest of the population. Resilience is not
a stable variable and may be improved by treatment.
Increased resilience corresponds to a higher level of
improvement in the general condition [5]. Thus, in this
study we aim to explore the bidirectional relationship
between resilience scores and the expression of symptoms in
the context of the treatment over time. Ninety-five patients
from the clinical sample were measured three times using
the RSA (Resilience Scale for Adults) [35] and the
CORE-OM (Clinical Outcomes in Routine Evaluation
Outcome Measure) [36,37] before and after receiving
psychotherapy, both in combination with and without
pharmacological treatment.
2. Method
2.1. Subjects
Ninety-five patients diagnosed with affective and anxiety
disorders from a clinical sample were treated psychothera-
peutically with (n = 81) or without (n = 14) pharmacolog-
ical treatment at a psychotherapy day center. Diagnosis was
made by psychiatrists at the time when a person was entering
treatment. There were patients with anxiety, dissociative,
stress-related, somatoform and other nonpsychotic mental
disorders 30 (31.6%): mixed anxiety and depressive disorder
15 (50%); adjustment disorders 7 (23.3%); generalized
anxiety disorder 3 (10%); and other (F40.1, F41.3, F41.0,
F43.1, F44.7) 5 (16.7%); and people with mood (affective)
disorders 65 (68,4%): depressive episode 14 (21,5%); and
recurrent depressive disorder 51 (78,5%). There were certain
significant differences between two groups of our sample.
People treated psychotherapeutically with pharmacological
treatment were older (M = 34.70, SD = 10.15), gender
proportions were different — in this group were more
women (69 women and 12 men), in this group were more
people who are diagnosed for more than two years, people
who received only psychotherapy treatment were younger
(M = 26.00, SD = 9.48), gender proportions were equal and
there were more people who were diagnosed for less than
two years. Treatment at the psychotherapy day center
included intensive, structured, but short-term 6-week
psychotherapy treatment (if necessary, with pharmacother-
apy) involving different methods of psychotherapy (on the
average 78 various meetings, not only psychotherapy, over
six week or on the average 13 meetings over one week):
individual and group psychodynamic psychotherapy; art,
music, and movie therapy groups; relaxation groups; social
skills training groups; psycho-education; and self-help
groups.
According to statistical analysis, the participating clinical
sample did not differ from the total patient population that
the clinic serves with regard to gender and age. There were
77 (81.1%) women and 18 (18.9%) men. The mean age of
the clinical sample was 33.42 (SD = 10.47) with the ages of
participants ranging from 18 to 60 years.
2.2. Procedure
All the patients who were with affective and anxiety
disorders (diagnosed by psychiatrists in the first three days
when they arrived) were invited to participate in the study
during their treatment in the psychotherapy day center.
Those who had no other arrangements and were motivated to
participate stayed beyond official therapy hours to attend the
survey. Only seven patients with affective and anxiety
disorders refused to participate in the study. The study was
approved by the Committee for Medical Ethics. Informed
consent was obtained from all individual participants
included in the study. The questionnaire package was
handed out to participants and took a maximum of 30 min
 V. Pakalniškienė et al. / Comprehensive Psychiatry 69 (2016) 88–99
to complete. Participants could take the questionnaires home
but were instructed to fill them out alone. All the participants
were assessed three times: at the beginning of the treatment,
after treatment (after 6 weeks), and after a follow-up interval
of 6 months after the end of therapy.
2.3. Instruments
We used the RSA for measuring resilience. The Resilience
Scale for Adults, developed by Friborg, Hjemdal, Rosenvinge,
and Martinussen [14,38], is a multi-dimensional scale aimed at
assessing general characteristics of resilience among adults.
The RSA is a 33-item self-report scale which measures
resilience during the last month. RSA applies a seven-point
semantic differential scale in which each item has a positive
and a negative attribute at each end of the scale continuum. To
reduce acquiescence biases half of the items are reversely
scored. Scores vary between 33 and 231, with higher scores
indicating higher levels of resilience. Several studies support
the cross-cultural validity of the RSA [13,35,39–42]. The scale
consists of six factors indicating intrapersonal and interper-
sonal protective factors presumed to facilitate adaptation to
psychosocial adversities: positive perception of self (6 items),
positive perception of the future (4 items), social competence
(6 items), structured style (4 items), family cohesion (6 items),
and social resources (7 items).
Previous studies have found the RSA to be reliable and
valid [14,43,44], particularly in terms of discriminating
between clinical and healthy samples [14]. The validity and
reliability of the Lithuanian version of the Resilience Scale
for Adults were indicated in the results of a previous study
[35]. Cronbach's alpha for the RSA for this study sample at
all three time points ranged from .70 to .92.
To evaluate symptoms, we used the CORE-OM (Clinical
Outcomes in Routine Evaluation Outcome Measure), which
addresses global distress and is therefore suitable for use as
an initial screening tool and outcome measure. The
CORE-OM subjectively measures a patient's experienced
stress. It supports the assessment of service quality,
effectiveness, and efficiency. The measure is suitable for
use by specialists of all psychotherapy modalities. The
CORE-OM was designed to measure the effectiveness of
treatment for specific patients, treatment by individual
therapists, and treatment in different therapy centers as
well as to compare them. The 34 items of the measure cover
the following dimensions: subjective well-being (4 items),
problems/symptoms (12 items: anxiety [4 items], depression
[4 items], physical problems [2 items] and trauma [2 items]),
life functioning (12 items: general functioning [4 items],
close relationships [4 items] and social relationships [4
items]). In addition, it contains a risk/harm dimension (6
items: risk to self [4 items] and risk to others [2 items]). Items
are scored on a 5-point Likert scale from 0 (not at all) to 4 (all
the time). Separate domains and the overall measure are
problem scored (i.e., higher scores indicate more problems
even for the well-being scale). The mean of all 34 items can
91
be and was used as a global index of distress in this study.
The development of the instrument was explicitly aimed at
meeting psychometric research standards as well as the
requirements of clinical routine evaluations [45]. The
validity and reliability of the Lithuanian version of the
CORE-OM were indicated in the results of a previous study
[36]. Cronbach's alpha for the CORE-OM for our sample at
all three time points ranged from .66 to .94.
2.4. Data analysis
Basic statistical analysis (mean value differences between
groups and over time) and the expression of symptoms and
resilience at each of the three waves of the survey were
compared using repeated ANOVA testing using SPSS
(Statistical Package in Social Sciences) 22.0 software.
Differences between time points were evaluated using least
significant difference (LSD) post hoc criteria.
To examine the relationships between resilience and
symptoms over time, we tested a cross-lagged panel design
model with Mplus 5.0 [46]. For these analyses, we used full
information maximum likelihood (FIML) because we used
raw data as the input file for the program and some of the
data were missing. The proportion of missing values could
be examined by a covariance “coverage” matrix provided by
Mplus software. This matrix provides an estimate of
available observations for each pair of variables. The
minimum recommended coverage is .10 [46]. In this study,
the coverage in all tested models ranged from .94 to 1.00.
The conceptual model is presented in Fig. 1. In total we
tested 25 models since there were four subscales measuring
the expression of symptoms (well-being, problems/symp-
toms, functioning, risk/harm) and six subscales of the RSA
(perception of self, planned future, social competence,
structured style, family cohesion, and social resources).
Two variables were used in one model, for example
well-being and perception of self or functioning and planned
future. Instead of the total CORE-OM measure displayed in
Fig. 1, we used one of four aspects representing the
expression of symptoms. Concordantly one of the RSA
components was used instead of the overall RSA construct.
In this model variables at one time point were correlated with
each other. In all the models tested in this study, we
controlled for gender and age at Time 1. Besides
autoregressive paths from one time to another we added
autoregressive paths from all previous time points because of
strong relationships between all time points' measures. For
example, all three resilience measures correlated over time
and correlation coefficients ranged from .45 to .62. Thus, to
account for these strong relationships over time, we added
additional paths to the model.
All cross-lagged panel design models tested in this study
were evaluated using several goodness-of-fit indices: the CFI
(Comparative Fit Index) [47], the RMSEA (Root Mean
Square Error of Approximation) [48], and the TLI (Tucker–
Lewis Index) [49]. The CFI and TLI values greater than .90
92 V. Pakalniškienė et al. / Comprehensive Psychiatry 69 (2016) 88–99
Time 1 Time 2 Time 3

RSA RSA RSA

GENDER

AGE

CORE-OM CORE-OM CORE-OM

Fig. 1. Conceptual model of relations between resilience and distress.

represent adequate fit with the data; [50] values greater than
.95 suggest a good fit [51]. RMSEA values less than .08
represent reasonable errors of approximation; values less
than .05 indicate a close fit with the data [48].
3. Results
3.1. Levels of resilience and global distress over time
In order to evaluate levels of resilience and distress over
time, we compared mean values using repeated measures
ANOVA. Results are presented in Table 1. Results suggest
that there are statistically significant differences in resilience
(total resilience score). While comparing mean values using
the post hoc LSD test, it is seen that total resilience scores at
Time 3 are significantly higher compared to Time 1 and
Time 2 (mean difference = .44, p b .001, mean differ-
ence = .25, p = .018, Time 3 from Time 1 and Time 2
accordingly), while Time 1 and Time 2 scores do not differ
from each other (mean difference = − .19, p = .055). This
suggests that over time resilience increases and stays stable
after the treatment.
Talking about dimensions of resilience we can see in
Table 1 that social competence and social resources do not
differ significantly over time. However, levels of other
dimensions of resilience significantly differ over time. Also,
from Table 1, it can be seen that all the resilience dimension
scores at Time 3 are higher compared to Time 1 or Time 2.
Comparing mean values using the post hoc LSD test, results
suggest that family cohesion, at Time 3 is significantly
higher compared to Time 1 and Time 2 (mean difference =
.53, p = .001, mean difference = .49 p = .001, Time 3 from
Time 1 and Time 2 accordingly), while Time 1 and Time 2
scores do not differ from each other (mean difference = −
.05, p = .733). Structured style also at Time 3 is significantly
higher compared to Time 1 and Time 2 (mean difference =
.38, p = .021, mean difference = 36 p = .019, Time 3 from
Time 1 and Time 2 accordingly), while Time 1 and Time 2
scores do not differ from each other (mean difference = −
.17, p = .911). Perception of self scores at Time 3 is the
highest over time and is significantly different only from
Time 1 scores (mean difference = .52, p = .003). Scores for
planned future at Time 1 are the lowest compared to other
time points and significantly differ from scores for Time 2

Table 1
Means and standard deviations of all measures used in the cross-lagged models and their comparison over time using repeated measures ANOVA.
Time 1 Time 2 Time 3 Wilks' Lambda F p
Measures M (SD) M (SD) M (SD)
Resilience
Total resilience 4.02 (.81) 4.22 (.88) 4.46 (.90) .81 7.02 .002
Perception of self 3.46 (1.34) 3.72 (1.35) 3.98 (1.36) .86 4.80 .012
Planned future 3.21 (1.55) 3.74 (1.66) 4.07 (1.79) .78 8.05 .001
Social competence 4.26 (1.40) 4.50 (1.21) 4.50 (1.29) .92 2.45 .097
Family cohesion 3.75 (1.53) 3.79 (1.39) 4.28 (1.31) .79 7.46 .001
Social resources 4.82 (1.19) 5.03 (1.21) 5.15 (1.16) .91 3.02 .057
Structured style 4.26 (1.46) 4.28 (1.24) 4.64 (1.56) .89 3.64 .033

Expression of symptoms
Global index 1.81 (.62) 1.45 (.64) 1.31 (.69) .64 16.67 .000
Well-being 2.21 (.80) 1.77 (.87) 1.57 (.98) .66 15.24 .000
Symptoms/problems 2.24 (.77) 1.78 (.90) 1.58 (.92) .60 19.93 .000
Functioning 2.10 (.74) 1.59 (.63) 1.48 (.67) .60 19.48 .000
Risk .51 (.62) .30 (.42) .28 (.46) .87 4.31 .018
Note. Significant differences are marked in boldface.
 V. Pakalniškienė et al. / Comprehensive Psychiatry 69 (2016) 88–99 93

and Time 3 (mean difference = − .53, p = .009, mean
difference = − .86, p b .001, Time 3 from Time 1 and
Time 2 accordingly), while Time 2 and Time 3 mean scores
do not differ from each other (mean difference = − .34, p =
.059). Thus, all the resilience domains increase over time.
Also, resilience domains stay stable after the treatment.
Results in Table 1 suggest that there are statistically
significant differences in all the expressions of distress
(symptoms) over time. The post hoc LSD test revealed that
global distress indices at Time 1 are significantly different
from Time 2 (mean difference = .36, p b .001) and Time 3
(mean difference = .50, p b .001), while Time 2 and Time 3
measures do not differ significantly (mean difference = .14,
p = .134). The post hoc LSD test also revealed that global
distress dimensions – well-being, problems, functioning, and
risk indices – at Time 1 are significantly different from Time
2 (mean difference = .44, p b .001, mean difference = .47,
p b .001, mean difference = .51, p b .001, mean differ-
ence = .21, p = .007, for well-being, problems, functioning
and risk, accordingly) and Time 3 (mean difference = .64,
p b .001, mean difference = .66, p b .001, mean differ-
ence = .62, p b .001, mean difference = .23, p = .012),
while Time 2 and Time 3 measures do not differ significantly
(mean difference = .20, p = .117, mean difference = .20,
p = .097, mean difference = .12, p = .221, mean differ-
ence = .03, p = .695, for well-being, problems, functioning
and risk, accordingly). Taken together, all the domains
indicate higher levels of distress before the treatment
compared to right after the treatment or half a year after
the treatment. Expression of distress stays stable after the
treatment. This suggests that over time resilience increases
while symptoms decrease. Also, during treatment resilience
increases and stays stable after the treatment.
3.2. Differences according to treatment for resilience and
distress
Considering that there were patients who received only
psychotherapy treatment and patients who received combined
(psychotherapy and pharmacotherapy) treatment for six weeks,
we compared all the variables at all time points between these
groups using independent sample t test (Table 2). Treatment
may be an environmental factor related to resilience. The results
in Table 2 suggest that there are only a few differences between
the two groups of patients at the beginning of treatment.
However, there were no differences in global resilience between
these two groups. However, there were differences in certain
dimensions of resilience. Patients who received only psycho-
therapeutic treatment already rated themselves as having better
perception of self at the beginning of treatment compared to
patients who received the combined treatment. These same
patients had a better perception of self at the end of the six-week
treatment. There were also differences in planned future —
patients who received only psychotherapeutic treatment rated
themselves better on this component 6 months after the end of
therapy. Other components did not differ between groups either
at the end of six weeks or at six months after the treatment. This
suggests that both groups of patients were similar in their level of
resilience at all three time points, especially at six months after
treatment.
Talking about expression of symptoms, the results in
Table 2 suggest that there were differences in global index of
distress, well-being, and problems. Patients who received
only psychotherapeutic treatment already rated themselves
as having better well-being, fewer problems and symptoms
at the beginning of treatment compared to patients who
received the combined treatment. Other components did not

Table 2
Means and standard deviations and their comparison between different treatment groups of all measures at different time points using independent sample t test.
Treat1 Treat2 Treat1 Treat2 Treat1 Treat2
Measures Time 1 Time 1 t p Time 2 Time 2 t p Time 3 Time 3 t p
Resilience
Total resilience 3.87 (.80) 4.32 (.77) − 1.93 .057 4.17 (.91) 4.50 (.71) − 1.29 .20 4.46 (.94) 4.61 (.82) − .47 .642
Perception of self 3.14 (1.26) 4.58 (1.03) − 4.03 .000 3.56 (1.36) 4.52 (.91) − 2.55 .013 3.99 (1.43) 4.08 (.97) − .20 .840
Planned future 2.83 (1.58) 3.57 (1.36) − 1.65 .102 3.52 (1.66) 3.88 (1.63) − .73 .467 3.94 (1.82) 5.18 (1.09) − 2.07 .043
Social competence 4.21 (1.38) 4.55 (1.46) − .83 .410 4.54 (1.30) 4.97 (1.09) − 1.17 .245 4.47 (1.34) 4.75 (1.01) − .63 .533
Family cohesion 3.71 (1.45) 3.83 (1.77) − .27 .790 3.85 (1.46) 3.79 (1.27) .14 .887 4.33 (1.39) 4.00 (1.39) .68 .498
Social resources 4.70 (1.24) 4.94 (1.15) − .67 .505 4.93 (1.36) 5.22 (.99) − .76 .449 5.20 (1.15) 5.00 (1.22) .50 .621
Structured style 4.19 (1.41) 4.04 (1.35) .38 .708 4.33 (1.27) 4.11 (1.10) .62 .535 4.61 (1.57) 4.70 (1.43) − .18 .861

Expression of symptoms
Global index 2.00 (.61) 1.53 (.54) 2.75 .007 1.53 (.66) 1.20 (.49) 1.77 .081 1.32 (.72) 1.20 (.62) .48 .636
Well-being 2.45 (.87) 1.73 (.61) 2.98 .004 1.84 (.92) 1.45 (.75) 1.45 .137 1.57 (.99) 1.50 (.87) .20 .844
Symptoms/problems 2.50 (.74) 1.88 (.73) 2.86 .005 1.91 (.88) 1.46 (.73) 1.77 .079 1.58 (.96) 1.47 (.83) .35 .728
Functioning 2.30 (.71) 1.91 (.70) 1.91 .060 1.64 (.67) 1.41 (.53) 1.25 .213 1.49 (.70) 1.29 (.60) .83 .408
Risk .56 (.60) .35 (.40) 1.31 .194 .34 (.46) .11 (.14) 1.89 .064 .27 (.47) .28 (.42) − .09 .930
Note. Treat1 — pharmacological and psychotherapy treatment group, Treat2 — only psychotherapy treatment group. Significant differences are marked in
boldface.
94 V. Pakalniškienė et al. / Comprehensive Psychiatry 69 (2016) 88–99

Table 3
Fit indices for cross-lagged panel design models including resilience and distress.
Fit indices
Model χ2 df p CFI TLI RMSEA
Global index — Total resilience 6.37 10 .78 1.00 1.00 .00
Well-being — Perception of self 5.53 10 .85 1.00 1.00 .00
Symptoms/problems — Perception of self 5.18 10 .88 1.00 1.00 .00
Functioning — Perception of self 3.40 10 .97 1.00 1.00 .00
Risk — Perception of self 8.67 10 .56 1.00 1.00 .00
Well-being — Planned future 12.70 10 .24 .99 .97 .05
Symptoms/problems — Planned future 8.10 10 .62 1.00 1.00 .00
Functioning — Planned future 7.31 10 .70 1.00 1.00 .00
Risk — Planned future 13.39 10 .20 .97 .93 .06
Well-being — Social competence 9.75 10 .46 1.00 1.00 .00
Symptoms/problems — Social competence 8.80 10 .55 1.00 1.00 .00
Functioning — Social competence 7.26 10 .70 1.00 1.00 .00
Risk — Social competence 6.22 10 .80 1.00 1.00 .00
Well-being — Family cohesion 7.76 10 .65 1.00 1.00 .00
Symptoms/problems — Family cohesion 5.36 10 .87 1.00 1.00 .00
Functioning — Family cohesion 5.71 1. .84 1.00 1.00 .00
Risk — Family cohesion 3.55 10 .97 1.00 1.00 .00
Well-being — Social resources 9.84 10 .46 1.00 1.00 .00
Symptoms/problems — Social resources 6.04 10 .81 1.00 1.00 .00
Functioning — Social resources 3.61 10 .96 1.00 1.00 .00
Risk — Social resources 4.74 10 .91 1.00 1.00 .00
Well-being — Structured style 7.09 10 .72 1.00 1.00 .00
Symptoms/problems — Structured style 6.69 10 .75 1.00 1.00 .00
Functioning — Structured style 5.63 10 .85 1.00 1.00 .00
Risk — Structured style 8.60 10 .57 1.00 1.00 .00

differ between groups either at the end of six weeks or at six
months after the treatment. This suggests that both groups of
patients were similar in their level of distress at all three time
points, especially at six months after treatment.
3.3. Cross-lagged analysis
To test whether resilience may affect expression of
distress or vice versa over time, we tested the directions of
effects in the cross-lagged panel design model presented in
Fig. 1. A crossed-lagged model allows for the evaluation of
relationships over the course of time, and the model supplies
information about changes over time and the direction of
relationships between variables when controlling for their
relationship at the same time point. In all models we
controlled for age and gender at Time 1. We tested several
models: models including different scales of resilience and
different aspects of distress. In total we tested 25 models
since there were five subscales measuring expression of
distress (global index, well-being, problems, functioning,
risk) and total score of resilience and six subscales of the
RSA (perception of self, planned future, social competence,
structured style, family cohesion and social resources).
Goodness-of-fit indices of all 25 models are presented in
Table 3. The fit of all tested models was adequate.
Standardized estimates of all stability and cross-paths in
these models are presented in Table 4.
Results from almost all the models suggest that distress
domains were moderately stable over time (standardized
autoregressive coefficients from .38 to of .52, from Time 1 to
Time 2, and from .26 to .46 from Time 2 to Time 3,
respectively). Distress domains were more stable from Time
1 to Time 2, while from Time 2 to Time 3 were less stable. In
some cases stability even from Time 1 to Time 2 was not
significant (for example for well-being — values of
well-being in the model with perception of self or planned
future). Resilience was also moderately stable over time
(standardized autoregressive coefficients from .21 to of .66
for perception of self, from .18 to .59 for planned future,
from .27 to .80 for social competence, from .28 to .80 for
structures style, from .36 to .74 for family cohesion, from .38
to .65 for social resources, and from .22 to .65 for global
index). The consistency of resilience components over time
suggests that earlier levels of resilience determine later
expression of resilience, at Time 2 and Time 3. Generally
speaking, this seems to be true for expressions of distress as
well.
Do levels of resilience at the beginning of psychotherapy
determine the expression of distress after the therapy or vice
versa? Results in Table 4 indicate that perception of self and
planned future as components of the concept of resilience
affect dynamics of well-being as one particular indicator
between surveys directly and 6 months after treatment.
Higher values for perception of self and planned future
before the treatment and after the treatment led to better
self-reported well-being right after the treatment and at
follow-up (Est = − .34**, Est = − .27* for perception from
Time 1 to Time 2 and Time 2 to Time 3, respectively;
 V. Pakalniškienė et al. / Comprehensive Psychiatry 69 (2016) 88–99 95

Table 4
Standardized estimates of stability and cross-paths between various aspects of resilience and distress.
Stability Directions
Model CORE CORE CORE RSA RSA RSA RSA RSA CORE CORE
T1 — T2 — T1 — T1 — T2 — T1 — T1 — T2 — T1 — T2 —
CORE T2 CORE T3 CORE T2 RSA T2 RSA T3 RSA T3 CORE T2 CORE T3 RSA T2 RSA T3
Total — TotalR .42*** .33* .20* .65*** .39** .22* − .12 − .03 − .02 − .11
Well — Percep .16 .15 .33*** .68*** .43** .24** − .34** − .27* − .03 − .08
Probl — Percep .42*** .30** .21* .69*** .43** .23* − .16 − .14 − .02 − .09
Funk — Percep .42*** .14 .15 .69*** .43** .21* − .17* − .32* − .01 − .12
Risk — Percep .37*** .20 .03 .66*** .51*** .13 − .21* − .09 − .12 − .09
Well — Future .24* .14 .33*** .56*** .57*** .30** − .25* − .26* − .05 .14
Probl — Future .48*** .34** .22* .56*** .52*** .25* − .05 − .08 − .08 .01
Funk — Future .48*** .13 .15 .57*** .59*** .23* − .07 − .28* − .05 .10
Risk — Future .41*** .14 .04 .55*** .53*** .18* − .13 − .16 − .17* − .07
Well — Soccom .38*** .36** .34*** .80*** .50*** .28* .02 .06 .04 .02
Probl — Soccom .50*** .43*** .18* .79*** .50*** .28* .07 .09 .03 − .02
Funk — Soccom .49*** .34** .12 .80*** .46** .32** − .09 − .08 .04 − .01
Risk — Soccom .45*** .26* .07 .79*** .46** .27* − .20* .08 − .06 − .18*
Well — Famcoh .38*** .30** .41*** .80*** .52*** .27* − .01 − .01 .03 .01
Probl — Famcoh .49*** .40*** .22* .79*** .52*** .26* − .02 .02 − .03 .02
Funk — Famcoh .49*** .36** .16 .77*** .60*** .20* − .05 .03 − .07 .05
Risk — Famcoh .40*** .28* .08 .80*** .49*** .28* − .23* .11 − .02 − .07
Well — Socres .37*** .35** .40*** .73*** .36** .39** − .04 .09 .01 − .02
Probl — Socres .50*** .46*** .21* .72*** .31* .41** .02 .17 − .05 − .12
Funk — Socres .43*** .42** .12 .73*** .28* .40** − .17* .09 − .01 − .15
Risk — Socres .41*** .29* .06 .74*** .42** .36** − .17* .14 .04 .02
Well — Strsty .39*** .32** .38** .62*** .40*** .41*** .04 .02 .03 .04
Probl — Strsty .52*** .40** .21* .63*** .38** .42*** .10 .04 .10 − .04
Funk — Strsty .52*** .35** .14 .65*** .40*** .40*** .07 − .03 .16 − .01
Risk — Strsty .47*** .24* .09 .63*** .39*** .40*** .08 − .23* .08 − .04
Note. ***p b .001; **p b .01; *p b .05. Well — Well-being, Probl — Symptoms/problems, Funk — Functioning, Percep — Perception of self, Future —
Planned future, Soccom — Social competence, Famcoh —– Family cohesion, Socres — Social resources, Strsty — Structured style, Total — Global index,
TotalR — Total resilience.

Est = − .25*, Est = − .26* for planned future from Time 1 to
Time 2 and Time 2 to Time 3, respectively). Perception of
self also affects functioning at both time lags (Est = − .17*,
Est = − .32* for Time 1 to Time 2 and Time 2 to Time 3,
respectively). Perception of self can also predict lower risk
from Time 1 to Time 2 (Est = − .21*). Results suggest that
social competence, family cohesion and social resources at
Time 1 predict lower risk right after treatment (Est = − .20*,
Est = − .23*, Est = − .17*, for social competence, family
cohesion, and social resources respectively). Social re-
sources at Time 1 could predict better functioning at Time
2 (Est = − .17*), while planned future at Time 2 affects
better functioning at Time 3 (Est = − .28*). Also, structured
style right after treatment affects lower risk in six months
(Est = − .23*). Other aspects of resilience did not determine
levels of distress over time (see Table 4).
Furthermore, results show that higher levels of risk
can lead to a lower expression of planned future and
structures style when compared before and right after
treatment (Est = − .17* and Est = − .23*, for planned
future and structures style, respectively) and also to
lower expression of social competence when compared
after 6 weeks of treatment and after half a year of
treatment (Est = − .18*).
In all the models we controlled for gender and age. In all
the models with well-being included, gender predicted levels
of well-being at Time 1 (Est = .21*). This result suggests
that women, overall, have worse or lower levels of
well-being. In all the models that included the social
competence measure, gender predicted levels of social
competence at Time 1 (Est = .21*). Results indicate that
women have worse self-reported social competence scores.
Age predicted family cohesion at Time 1 (Est = .31*) in all
the models with family cohesion. Older age related to worse
self-reported family cohesion.
Are the links between psychological resistance and
distress different in patients who have received different
treatment? To determine whether the results of the assessed
models differ among individuals who received different
treatment, all the models were tested for group effect and for
moderation effect. The study included patients who were
given only psychotherapy treatment (14 patients), and
patients who were given a combined (pharmacotherapy
and psychotherapy) treatment (81 patients). Assessment of
all 25 models between the groups revealed few differences.
There were no significant differences in cross-paths, which
suggest that treatment is not related to an increase or decrease
in distress or resilience. However, patients who received the
96 V. Pakalniškienė et al. / Comprehensive Psychiatry 69 (2016) 88–99
combined treatment (psychotherapy and pharmacology)
have stronger stability paths for certain domains (such as
well-being, symptoms/problems, and risk), and stability
differs significantly from patients who received psychother-
apy treatment. It is understandable that these results did not
conclude that treatment could be responsible for improve-
ment, as there was no control. It might be that those in
combination treatment may have been more complicated and
have worse symptoms.
4. Discussion
Adult resilience as a predictor in the development of
psychiatric symptoms has been explored in the past [12].
However, the effects of psychiatric symptoms on resilience
were not controlled for. Thus, in this study we looked at
bidirectional relationships between distress domains and
resilience over time. We found that levels of resilience
measured by RSA scores seem to have a certain prognostic
value for the reduction of symptoms over the course of
treatment. Considering that previous studies found that
higher scores for resilience were related to unchanged levels
of psychiatric symptoms when exposed to stressful life
events [12], these findings were a bit unexpected. In this
study we did not control for stressful life events, only for
gender and age. It is possible that controlling for additional
stressful life events could change the results. However,
adolescent studies show that higher resilience scores for
personal dispositions, the availability of sources of social
support outside the family, and perceived levels of family
cohesion showed consistent and important significant
predictive relationships for levels of depression, anxiety,
stress, and obsessive–compulsive symptoms when age and
gender differences are controlled for [52]. In our study,
perception of self was the strongest predictor of fewer
symptoms over time when the stability of symptoms and
perception of self over time were controlled for. Social
competence, family cohesion, and social resources were also
related to less severe symptoms over time, but the results
were less stable than with perception of self. It appears that a
person's perception of self (which can be seen as a source of
personal resilience) along with some social aspects (envi-
ronmental source of resilience) can predict fewer symptoms
for people with affective and anxiety disorders in a way
similar as that for adolescents. The question is why the
similarity to adolescents? Or the key factor could be
internalizing psychiatric disorders because the study with
adolescents dealt with depression and anxiety [52]. In this
study patients had diagnosed anxiety or affective disorders,
which can be viewed as internalizing psychiatric disorders.
Thus, certain resilience aspects could predict fewer symp-
toms related to anxiety or depression. On the other hand, the
results suggest that decreased self-reported distress is not
directly related to increasing resilience over six weeks or six
months. Considering that resilience is rather stable over time
and symptoms are less stable, perhaps expression of distress
has no statistical power to predict resilience. However also it
might be that resilience can be increased by personal or
environmental sources and decrease in distress is not one of
them.
In this study all distress indicators decreased over time,
while resilience characteristics increased for the whole
sample. Patients in this study underwent treatment, thus
decreases in global distress were a result of treatment. Taking
into account that a common criterion for assessing the
efficacy or the effectiveness of psychotherapy or psycho-
pharmacological trials in treating mental disorders is to
measure the amount of decrease in psychiatric symptoms
[53], study results suggest that treatment was effective for
patients in the study. Assessment of reductions in psychiatric
symptoms is therefore still important, but a parallel increase
in a person's adaptive capabilities and the ability to cope
with life stressors are considered equally important when
examining the tenability of treatment trials [54]. Increase in
resilience over time supports the effectiveness of treatment.
However, there were no significant differences between
treatment types while evaluating models. Results suggest
that treatments (psychotherapy or psychopharmacological
with psychotherapy) were equally effective for the chosen
patients. In Lithuania, pharmacological treatment is better
available and therefore used with almost all patients, while
these results show that effects are similar between psycho-
therapy treatment and psychotherapy treatment with phar-
macology. Adding medicine to the treatment does not lead
directly to better results in dealing with anxiety or affective
disorders. This idea is worth examining on a deeper level
because many patients, if choosing their own type of
treatment, prefer psychotherapy to medicine [55,56].
Evaluating treatment results only by measuring the
reduction of distress (psychopathology) would mean looking
at the benefits of therapy from a very narrow perspective.
Successful treatment should not only relieve symptoms (i.e.,
get rid of something) but also foster the positive presence of
psychological capacities and resources [53]. According to
Ryff and Singer (1996), historically, mental health research
is dramatically weighted on the side of psychological
dysfunction and health is equated with the absence of illness
rather than the presence of wellness [57]. There is an
increasing awareness that the concept of recovery in clinical
psychiatry and psychology cannot simply be confounded
with response to treatment or limited to the reduction of
certain symptoms [58]. Increase in resilience over time for all
the patients and not finding any difference in resilience at
each time point between different treatment groups supports
this idea and suggests that treatment could be successful.
Considering that all the patients received psychotherapy
treatment would be easy to think that psychotherapy could be
responsible for this increase. However, there are suggestions in
the literature that an antidepressant drug, escitalopram, could
have an effect on depression, resilience to stress, and quality of
life in a randomized placebo-controlled double-blind trial.
 V. Pakalniškienė et al. / Comprehensive Psychiatry 69 (2016) 88–99
Researchers concluded that antidepressant use in depressed
family dementia caregivers with either major or minor
depression can be used to improve symptoms of depression,
boost resilience to stress, and improve coping with caregiver
stress [33]. Strengthening resilience through psychotherapy
might benefit, but pharmacological treatment cannot be
ignored.
It is known that better resilience is related to fewer
relapses [58]. Major clinical trials have underscored the fact
that full remission occurs in a minority of patients [59].
Various follow-up studies, in fact, have documented relapses
and recurrence in affective disorders [59]. Certain authors
refer to resilience as a set of attributes and resources that
prevent illness following adverse environmental circum-
stances in the general population and prevent relapse after
symptomatic remission in a clinical population [59]. Better
resilience could be a protective factor from relapse. Results
from this study suggest that resilience is moderately stable
over half a year and is also much more stable compared to
symptoms over this time. Consequently, this led us to
suspect that, during this period, relapses would be less likely
in this sample. In this study, follow-up was only half a year.
Six months could be too short a time to see changes in
resilience and expect relapses, thus further studies are needed
to test whether resilience is a protective factor for patients
with anxiety and affective disorders.
Taken together, the findings suggest that resilience is
significantly related to distress over time in the patient
sample. Higher resilience can be a protective factor and, with
treatment, give better results over time. Thus clinicians and
people working with patients with anxiety or affective
disorders should consider evaluating the resilience factor.
Increasing certain resilience aspects may offer better results
over the period of treatment. Resilience should be regarded
not only as the basis for successful adaptation as opposed to a
poor mental health outcome, but also the precondition for
psychological growth or the development of new capabilities
or a new perspective on life through that successful
adaptation. The reduction of psychopathological expression
achieved through treatment has been predicted by
pre-treatment levels of resilience. However, the RSA
measure appears to be of considerable prognostic value for
expected overall response to psychotherapy treatment as it
provides insight into a person's capacity to strengthen key
components of resilience itself, which can lead to improved
quality of living and protection from future illness. The RSA
represents a possible tool for predicting the effects of
treatment and optimizing the patient selection process.
5. Conclusions
Levels of resilience measured by RSA scores seem to
have certain prognostic value for the reduction of symptoms
over the course of treatment. Perception of self was the
strongest predictor of lower levels of distress over time when
97
distress and perception of self-stability is controlled for over
time. Results suggest that decreased distress symptoms do
not directly relate to increasing resilience over six weeks or
over six months. Considering that resilience is rather stable
over time and symptoms are less stable, it is possible that
resilience can be increased by personal or environmental
sources, but a decrease in distress is not one of them. In this
study distress decreased over time, while resilience charac-
teristics increased for the whole sample. The increase in
resilience over time could support the effectiveness of
treatment. However, there were no significant differences
between treatment types while evaluating models. Results
suggest that treatments (psychotherapy or psychopharmaco-
logical treatment with psychotherapy) were equally effective
for the chosen patients.
Acknowledgment
We owe thanks to the patients and staff of the
psychotherapy day center who participated in the study.
This research was supported by a PhD grant distributed by
Vilnius University and received by Rima Viliūnienė, one of
the authors.
There are no conflicts of interest.
References
[1] Wald J, Taylor S, Asmundson GJ, Jang KL, Stapleton J. Literature
review of concepts: psychological resiliency. Toronto: Defence R&D
Canada; 2008.
[2] Charney DS. Psychobiological mechanism of resilience and vulnerabil-
ity: implications for successful adaptation to extreme stress. Psychiatry
2004;161:195-216, http://dx.doi.org/10.1176/appi.ajp.161.2.195.
[3] Feder A, Nestler EJ, Charney DS. Psychobiology and molecular
genetics of resilience. Nat Rev Neurosci 2009;10:446-57, http://
dx.doi.org/10.1038/nrn2649.
[4] Luthar SS, Cicchetti D, Becker B. The construct of resilience: a critical
evaluation and guidelines for future work. Child Dev 2000;71:543-62,
http://dx.doi.org/10.1016/j.biotechadv.2011.08.021.Secreted.
[5] Connor KM, Davidson JRT. Development of a new resilience scale:
the Connor-Davidson resilience scale (CD-RISC). Depress Anxiety
2003;18:76-82, http://dx.doi.org/10.1002/da.10113.
[6] Russo SJ, Murrough JW, Han M-H, Charney DS, Nestler EJ.
Neurobiology of resilience. Nat Neurosci 2012;15:1475-84, http://
dx.doi.org/10.1038/nn.3234.
[7] Joseph S, Linley PA. Growth following adversity: theoretical
perspectives and implications for clinical practice. Clin Psychol Rev
2006;26:1041-53, http://dx.doi.org/10.1016/j.cpr.2005.12.006.
[8] Southwick SM, Vythilingam M, Charney DS. The psychobiology of
depression and resilience to stress: implications for prevention and
treatment. Annu Rev Clin Psychol 2005;1:255-91, http://dx.doi.org/
10.1146/annurev.clinpsy.1.102803.143948.
[9] Herrman H, Stewart DE, Diaz-Granados N, Berger EL, Jackson B,
Yuen T. What is resilience ? Psychiatry 2011;56:258-65.
[10] Miller AM, Chandler PJ. Acculturation, resilience, and depression in
midlife women from the former soviet union. Nurs Res 2002;51:26-32,
http://dx.doi.org/10.1097/00006199-200201000-00005.
[11] Heckman CJ, Clay DL. Hardiness, history of abuse and women's
health. J Health Psychol 2005;10:767-77, http://dx.doi.org/10.1177/
1359105305057312.
98 V. Pakalniškienė et al. / Comprehensive Psychiatry 69 (2016) 88–99
[12] Hjemdal O, Friborg O, Stiles TC, Rosenvinge JH, Martinussen M.
Resilience predicting psychiatric symptoms: a prospective study of
protective factors and their role in adjustment to stressful life events.
Clin Psychol Psychother 2006;13:194-201, http://dx.doi.org/10.1002/
cpp.488.
[13] Hjemdal O, Roazzi A, Dias MDGBB, Friborg O. The cross-cultural
validity of the Resilience Scale for Adults: a comparison between
Norway and Brazil. BMC Psychol 2015;3:18, http://dx.doi.org/
10.1186/s40359-015-0076-1.
[14] Friborg O, Hjemdal O, Rosenvinge JH, Martinussen M. A new rating
scale for adult resilience: what are the central protective resources
behind healthy adjustment? Methods Psychiatr Res 2003;12:65-76,
http://dx.doi.org/10.1002/mpr.143.
[15] Friborg O, Hjemdal O, Martinussen M, Rosenvinge JH. Empirical
support for resilience as more than the counterpart and absence of
vulnerability and symptoms of mental disorder. J Individ Differ
2009;30:138-51, http://dx.doi.org/10.1027/1614-0001.30.3.138.
[16] Garmezy N, Stevenson JE. Stress-resistant children: the search for
protective factors recent research in developmental psychopathology.
Child Psychol Psychiatr 1985;4:213-33.
[17] Garmezy N, Rutter M. Acute reactions to stress. Child Adolesc
Psychiatry Mod Approaches 1985;2:152-76.
[18] Garmezy N, Rutter M. Stress, coping, and development in children;
1983.
[19] Rutter M. Resilience in the face of adversity. Protective factors and
resistance to psychiatric disorder. Psychiatry 1985;147:598-611,
http://dx.doi.org/10.1192/bjp.147.6.598.
[20] Seligman MEP, Csikszentmihalyi M. Positive psychology — an
introduction. Am Psychol 2000;55:5-14, http://dx.doi.org/10.1037/
0003-066x.55.1.5.
[21] Werner EE, Smith RS. Overcoming the odds: high risk children from
birth to adulthood. Overcoming odds high risk child from birth to
adulthood; 1992. [Chapters 1, 4, & 9].
[22] Rutter M. Resilience concepts and findings: implications for family
therapy. J Fam Ther 1999;21:119, http://dx.doi.org/10.1111/1467-
6427.00108.
[23] MacDermid SM, Samper R, Schwarz R, Nishida J, Nyaronga D.
Understanding and promoting resilience in military families; 2008.
[24] Werner EE. Journeys from childhood to midlife: risk, resilience, and
recovery. Pediatrics 2004;114:492, http://dx.doi.org/10.1542/
peds.114.2.492.
[25] Costa PT, Terracciano A, McCrae RR. Gender differences in
personality traits across cultures: robust and surprising findings. J
Pers Soc Psychol 2001;81:322-31, http://dx.doi.org/10.1037/0022-
3514.81.2.322.
[26] Feingold A. Gender differences in personality: a meta-analysis.
Psychol Bull 1994;116:429-56, http://dx.doi.org/10.1037/0033-
2909.116.3.429.
[27] Kling KC, Hyde JS, Showers CJ, Buswell BN. Gender differences in
self-esteem: a meta-analysis. Psychol Bull 1999;125:470-500, http://
dx.doi.org/10.1037/0033-2909.125.4.470.
[28] Lynn R, Martin T. Gender differences in extraversion, neuroticism, and
psychoticism in 37 nations. J Soc Psychol 1997;137:369-73, http://
dx.doi.org/10.1080/00224549709595447.
[29] Kessler RC, McLeod JD. Sex differences in vulnerability to
undesirable life events. Am Sociol Rev 1984;49:620, http://
dx.doi.org/10.2307/2095420.
[30] Maciejewski PK, Prigerson HG, Mazure CM. Sex differences in event-
related risk for major depression. Psychol Med 2001;31:593-604,
http://dx.doi.org/10.1017/S0033291701003877.
[31] Min JA, Jung YE, Kim DJ, Yim HW, Kim JJ, Kim TS, et al.
Characteristics associated with low resilience in patients with
depression and/or anxiety disorders. Qual Life Res 2013;22:231-41,
http://dx.doi.org/10.1007/s11136-012-0153-3.
[32] Davidson J, Stein DJ, Rothbaum BO, Pedersen R, Szumski A, Baldwin
DS. Resilience as a predictor of treatment response in patients with
posttraumatic stress disorder treated with venlafaxine extended release
or placebo. J Psychopharmacol 2012;26:778-83, http://dx.doi.org/
10.1177/0269881111413821.
[33] Lavretsky H, Siddarth P, Irwin MR. Improving depression and
enhancing resilience in family dementia caregivers: a pilot randomized
placebo-controlled trial of escitalopram. Geriatr Psychiatry
2010;18:154-62, http://dx.doi.org/10.1097/JGP.0b013e3181beab1e.
[34] Southwick SM, Charney DS. The science of resilience: implications
for the prevention and treatment of depression. Science
2012;338:79-82, http://dx.doi.org/10.1126/science.1222942.
[35] Hilbig J, Viliuniene R, Friborg O, Pakalniškiene V, Danilevičiute V.
Resilience in a reborn nation: validation of the Lithuanian Resilience
Scale for Adults (RSA). Compr Psychiatry 2015;60:126-33, http://
dx.doi.org/10.1016/j.comppsych.2015.02.003.
[36] Viliuniene R, Evans C, Hilbig J, Pakalniškienė V, Danilevičiūtė V,
Laurinaitis E, et al. Translating the Clinical Outcomes in Routine
Evaluation Outcome Measure (CORE-OM) into Lithuanian. Psychiatry
2013;67:305-11, http://dx.doi.org/10.3109/08039488.2012.745599.
[37] Barkham M, Gilbert N, Connell J, Marshall C, Twigg E. Suitability
and utility of the CORE-OM and CORE-A for assessing severity of
presenting problems in psychological therapy services based in
primary and secondary care settings. Psychiatry 2005;186:239-46,
http://dx.doi.org/10.1192/bjp.186.3.239.
[38] Hjemdal O, Friborg O, Martinussen M, Rosenvinge JH. Preliminary
results from the development and validation of a Norwegian scale for
measuring adult resilience. J Nor Psychol Assoc 2001;38:310-7.
[39] Jowkar B, Friborg O, Hjemdal O. Cross-cultural validation of the
Resilience Scale for Adults (RSA) in Iran. Psychol 2010;51:418-25,
http://dx.doi.org/10.1111/j.1467-9450.2009.00794.x.
[40] Bonfiglio NS, Renati R, Hjemdal O, Friborg O. The Resilience Scale
for Adults in Italy: a validation study comparing clinical substance
abusers with a nonclinical sample. Psychol Addict Behav 2016, http://
dx.doi.org/10.1037/adb0000176.
[41] Capanna C, Stratta P, Hjemdal O, Collazzoni A, Rossi A. The Italian
validation study of the Resilience Scale for Adults (RSA). Appl
Psychol Bull 2015;272:16-24.
[42] Hjemdal O, Friborg O, Braun S, Kempenaers C, Linkowski P, Fossion
P. The Resilience Scale for Adults: construct validity and measurement
in a Belgian sample. Test 2011;11:53-70, http://dx.doi.org/10.1080/
15305058.2010.508570.
[43] Friborg O, Hjemdal O. Resilience as a measure of adaptive capacity. J
Nor Psychol Assoc 2004;41:206-8.
[44] Friborg O, Barlaug D, Martinussen M, Rosenvinge JH, Hjemdal O.
Resilience in relation to personality and intelligence. Methods
Psychiatr Res 2005;14:29-42, http://dx.doi.org/10.1002/mpr.15.
[45] Evans C, Mellor-Clark J, Margison F, Barkham M, Audion K, Connell
J, et al. CORE: clinical outcomes in routine evaluation. J Ment Health
2000;9:247-55, http://dx.doi.org/10.1080/jmh.9.3.247.255.
[46] Muthén L, Muthén B. Mplus user's guide6th ed. ; 2012.
[47] Bentler PM. Comparative fit indexes in structural models. Psychol Bull
1990;107:238-46, http://dx.doi.org/10.1037/0033-2909.107.2.238.
[48] Browne MW, Cudeck R. Alternative ways of assessing model fit.
Sociol Methods Res 1992;21:230-58 doi:0803973233.
[49] Tucker LR, Lewis C. A reliability coefficient for maximum likelihood
factor analysis. Psychometrika 1973;38:1-10, http://dx.doi.org/
10.1007/BF02291170.
[50] Bentler PM, Bonett DG. Significance tests and goodness of fit in the
analysis of covariance structures. Psychol Bull 1980;88:5-606, http://
dx.doi.org/10.1037/0033-2909.88.3.588.
[51] Hu L, Bentler PM. Fit indices in covariance structure modeling:
sensitivity to underparameterized model misspecification. Psychol
Methods 1998;3:424-53, http://dx.doi.org/10.1037/1082-989X.3.4.424.
[52] Hjemdal O, Vogel PA, Solem S, Hagen K, Stiles TC. The relationship
between resilience and levels of anxiety, depression, and obsessive–
compulsive symptoms in adolescents. Clin Psychol Psychother
2011;18:314-21, http://dx.doi.org/10.1002/cpp.719.
[53] Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol
2010;65:98-109, http://dx.doi.org/10.1037/a0018378.
 V. Pakalniškienė et al. / Comprehensive Psychiatry 69 (2016) 88–99
[54] Blatt SJ, Zuroff DC. Empirical evaluation of the assumptions in
identifying evidence based treatments in mental health. Clin
Psychol Rev 2005;25:459-86, http://dx.doi.org/10.1016/
j.cpr.2005.03.001.
[55] Iacoviello BM, McCarthy KS, Barrett MS, Rynn M, Gallop R, Barber
JP. Treatment preferences affect the therapeutic alliance: implications
for randomized controlled trials. J Consult Clin Psychol
2007;75:194-8, http://dx.doi.org/10.1037/0022-006X.75.1.194.
[56] Chilvers C, Dewey M, Fielding K, Gretton V, Miller P, Palmer B, et al.
Antidepressant drugs and generic counselling for treatment of major
99
depression in primary care: randomised trial with patient preference
arms. Br Med J 2001;322:772-5.
[57] Ryff CD, Singer B. Psychological well-being: meaning, measurement,
and implications for psychotherapy research. Psychother Psychosom
1996;65:14-23, http://dx.doi.org/10.1159/000289026.
[58] Fava GA, Tomba E. Increasing psychological well-being and
resilience by psychotherapeutic methods. J Pers 2009;77:1903-34,
http://dx.doi.org/10.1111/j.1467-6494.2009.00604.x.
[59] Fava GA, Ruini C, Belaise C. The concept of recovery in major depression.
Psychol Med 2007;37:307-17, http://dx.doi.org/10.2975/30.3.2007.171.173.