key: cord-0984400-vjhceci9
authors: Thomas, Melissa M.; Pietrzak, Robert H.; Nguyen, Dana R.; Ryan, Diane; Southwick, Steven M.; Mazure, Carolyn M.
title: Psychological Resilience in West Point Graduates: Results From a Nationally Representative Study
date: 2021-11-05
journal: Chronic Stress (Thousand Oaks)
DOI: 10.1177/24705470211053850
sha: 476d21cff3a5757cd1feb3ca4a1a4e315807153f
doc_id: 984400
cord_uid: vjhceci9

Background: The purpose of this study was to examine factors associated with psychological resilience in a nationally representative sample of West Point graduates. Aims: The aims of this study were to (a) employ a dimensional approach to operationalizing psychological resilience in a trauma-exposed population that had been highly trained and educated in persisting in the face of stress, was previously unstudied, and in which we could examine correlates of resilience, (b) identify key psychosocial factors, character traits, health variables, military experiences, and coping strategies as potential correlates of psychological resilience; and (c) examine whether reported gender moderated any of these associations in this population. Methods: A nationally representative sample of 1342 West Point graduates after gender integration from classes 1980 to 2011 were surveyed. Psychological resilience was operationalized using a discrepancy-based approach in which a measure of composite psychological distress (current posttraumatic stress disorder, generalized anxiety and depression symptoms) was regressed on measures of cumulative trauma burden. A multivariable linear regression model was then employed to identify factors that were independently associated with psychological resilience scores. Results: Purpose in life (29.8% of relative variance explained [RVE]), fewer perceived negative experiences in the military (20.6% RVE), social support (9.6% RVE), and grit (9.5% RVE) were the strongest correlates of psychological resilience scores for both women and men. Time in service was positively associated with resilience in women only. Conclusion: This study identifies key correlates of psychological resilience in West Point graduates, individuals who are highly trained to persevere in the face of stress and then were trauma-exposed. Most of these factors are modifiable and can be targeted in stress prevention and treatment interventions, especially for high-stress professions such as the military, frontline health care providers, and first responders.

Psychological resilience has been defined as the capacity to "bounce back" and adapt well in the face of stress and trauma. 1,2 A common thread across various definitions of resilience is the capacity to persevere in the face of adversity. Particularly now, considering the global, national, and personal stress and trauma resulting from the ongoing coronavirus disease 2019 pandemic, it is important to determine such factors so they can be potentially enhanced or learned in an effort to prevent and/or treat adverse health outcomes.

The concept of psychological resilience has been operationalized in various ways, including as a preexisting trait/characteristic; a response to trauma that may vary over time; and as a multidimensional construct. 3 Resilience has also been conceptualized as a dynamic process that may fluctuate over time, with emerging research suggesting an overlap in these various concepts of resilience, as well as key differences that may account for discrepancies in the prevalence of resilience across studies. 4, 5 To date, the majority of resilience studies have employed psychological resilience as a categorical outcome or response, grouping individuals as resilient (exposed to trauma yet having no or minimal subsequent psychopathology) or nonresilient (exposed to trauma with subsequent psychopathology). 6, 7 This approach has been applied in cross-sectional studies, as well as longitudinal studies of responses to traumatic events, which have identified a resilient trajectory characterized by minimal/no distress as the modal response to these events. [6] [7] [8] In contrast to a binary approach of operationalizing resilience, Amstadter and colleagues (2014) developed a novel quantitative "discrepancy-based" approach that yields a dimensional measure of psychological responses to trauma that range from highly vulnerable to highly resilient. 9 Using this approach, a measure of psychological distress is regressed onto a measure of trauma burden, and residual scores are computed and then inverted for each individual. 10 Thus, individuals with a high trauma burden who have lower than expected distress scores would be considered resilient. A notable feature of this approach is that it generates a full spectrum of dimensional scores that range from highly vulnerable (low trauma, high distress) to highly resilient (high trauma, low distress).

A recent study of 1046 Iraq/Afghanistan combat veterans found that this discrepancy-based approach to operationalizing resilience yielded resilience scores that were strongly inversely associated with psychiatric diagnoses, physical health concerns, and alcohol and drug use. 5 More recently, a study of a nationally representative sample of 2704 US military veterans found that somatic symptoms, emotional stability, and a secure attachment style were most strongly associated with resilience scores. 11 Taken together, these initial studies provide empirical support for the utility of a discrepancy-based approach to operationalizing resilience on a dimensional continuum, and for using this approach to identify factors associated with psychological resilience.

A broad range of factors has been linked to psychological resilience, including psychosocial factors, character traits, health variables, military experiences, and coping strategies. With regard to psychosocial factors, previous studies have found that purpose in life, supportive relationships or social connectedness, active lifestyle, and intrinsic religiosity/spirituality are associated with resilience. 7, [12] [13] [14] [15] For example, greater sense of purpose in life has previously been linked with better mental health, quality of life, as well as reduced rates of depression and higher levels of perceived psychological resilience. 16 Similarly, a large body of research has demonstrated an association between strong social ties and reduced incidence of mental health problems, as well as reduced likelihood of developing psychopathology following traumatic stress. 1 Conversely, trauma may reduce resiliency, especially trauma occurring in early life. [17] [18] [19] [20] Additional factors that may affect psychological resilience but are not generally studied in the resilience literature include health variables such as physical activity, sleep, medical conditions, as well as character traits such as grit, which is defined as perseverance and the pursuit of long-term goals. 21 Of particular relevance to military populations, positive and negative experiences specific to military service may also contribute to resilience.

Accumulating evidence suggests that certain of these risk and protective factors may be differentially related to psychological resilience in men and women. [22] [23] [24] [25] [26] [27] [28] For example, military stressors such as low unit support, deployment-related injury, and concerns about life and family disruptions during deployment are more strongly associated with posttraumatic stress disorder (PTSD) symptoms in women than in men. 27 Women also are more likely than men to solicit social support and to use emotion-focused coping strategies to manage distress, and have been found to demonstrate an increased benefit from psychotherapy. 24, 26 Collectively, these findings highlight the importance of considering the role of gender, meant to connote an internal sense of identity, as a potential moderator of risk and protective factors associated with psychological resilience. 29 In the current study, our first aim was to apply a discrepancy-based approach to operationalizing resilience in a nationally representative sample of West Point graduates, a population that is both highly trained to negotiate adverse experiences and, given the nature of military service, has a high potential for stress and trauma exposure. This approach generated resilience scores using measures of cumulative trauma burden and distress (ie, posttraumatic stress, depressive, and anxiety symptoms). The second aim was to examine how a broad range of general (eg, purpose in life) and population-specific (eg, perceptions of military service) factors related to resilience. The third aim was to determine if gender moderated any of the risk and protective factors examined as potential correlates of psychological resilience when using this approach. Given that characterization of factors associated with resilience is critical to informing prevention and treatment efforts, results from the current study are particularly relevant to populations that require psychological resilience in the context of high stress, such as military personnel, first responders, and health care providers.

Data were drawn from the Resiliency and Physical and Mental Health of Graduates of USMA Study, which was conducted from January through February 2018 using a webbased survey to assess sociodemographic, health, lived experience and psychosocial factors, as well as coping strategies. Validated measures were used that are similar to those of the National Health and Resilience in Veterans Study. 12 The study was approved by the Yale University Institutional Review Board, and reviewed by the West Point human protections committee. Our partnership with the West Point Association of Graduates achieved access to this population.

A survey recruitment announcement was emailed to 100% of contactable women graduates (n = 3126) and to a random sample (n = 5303) of 25% of contactable men graduates from the classes of 1980 to 2011. The study focused on classes starting with those enrolled in 1976, which was the first class to graduate women as well as men. 30 A second follow-up reminder email was sent to the same sample approximately 4 weeks later, and additional recruitment announcements were posted on the West Point Women Facebook group page and shared on individual class Facebook pages by volunteers, to reach a larger sample of women than the email recruitment. Participants in the study provided informed consent and completed an anonymous web-based survey.

The response rate for women was 20% (641 respondents) and for men was 13% (701 respondents); the overall response rate was 16%. Previous cohort studies of veterans using surveys have achieved response rates of 25% in the Millennium cohort study and 27% in the Connecticut OIF/ OEF Veterans Needs Assessment Survey. 31, 32 The current sample achieved a demographic profile similar to the overall post-Vietnam era West Point graduate population, with the exception that our sampling strategy intentionally overrepresented women (48% of respondents vs 12% of total graduates 1980-2011) to be able to analyze gender differences. The mean age of the sample was 45.7 (SD 9.3) years, which was consistent with a calculated population age range of 44.2 to 50.2 (based on the number of graduates per year; by law, entrants to the 4-year academy must be between the ages of 17-23). 33 Survey responders self-identified as 85.5% White, non-Hispanic; 4.3% African American or Black; 4.5% Hispanic or Latino; 2.2% Asian; 1.0% American Indian or Pacific Islander; and 2.4% multiracial or other (Table 2 ). Class statistics provided by the West Point Office of Institutional Research for the classes of 1981 to 2011 were comparable: 81.6% Caucasian; 6.3% African American; 4.8% Hispanic; 4.7% Asian; 0.6% Native American; 0.6% Pacific Islander; and 1.5% other. The stated goal for assignment into combat arms (eg, infantry, armor, aviation, engineer) of this West Point cadet cohort was 80% of the male graduate population and 20% of female graduates. 34 In fact, 80% of our male sample and 22% of our female sample reported assignment to a combat arms branch. Based on available data on all West Point graduates, our sample is representative of the target population. Table 1 lists and describes the assessments used in this study.

Data analyses proceeded in 4 steps, consistent with Overstreet et al. (2021) . 11 First, given that PTSD, anxiety, and depressive were highly correlated, loaded on a single factor, and demonstrated comparable magnitude associations with trauma exposures, we computed a composite index of current psychological distress (ie, the severity of current PTSD, anxiety, and depression symptoms) by conducting an exploratory factor analysis with promax rotation of total Posttraumatic Stress Disorder Checklist-5 (PCL-5), Patient Health Questionnaire-2 (PHQ-2), and Generalized anxiety disorder-2 (GAD-2) scores. Results of this analysis revealed that depression, anxiety and PTSD scores on these scales loaded onto a single factor (eigenvalue 2.04, 67.9% total variance explained); factor loadings were 0.870 for the PHQ-2 measure of depressive symptoms, 0.835 for the GAD-2 measure of anxiety symptoms, and 0.763 for the PCL-5 measure of PTSD symptoms.

Second, discrepancy-based psychological resilience scores were computed. The regression model included (a) count of adverse life experiences; (b) each individual life experience, and (c) the nature of index/worst trauma. This allowed us to account for severity/count of experiences, as well as the specific nature of lifetime experiences and index events when computing discrepancy based scores. This is important given data suggesting that certain exposures (eg, sexual assault) are associated with a higher conditional probability of developing trauma-related distress. 35 Total number of traumatic life experiences (β = 0.22, t = 4.41, P < .001), sexual assault (β = 0.12, t = 2.95, P = −.03), toxic exposure (β = 0.11, t = 2.82, P = .005), physical assault (β = 0.10, t = 2.82, P = .005), combat (β = 0.09, t = 1.99, P = .047), other sexual harassment (β = 0.14, t = 3.31, P = .001), and other trauma (β = 0.18, t = 3.93, P < .001) were significantly associated with psychological distress scores. Discrepancy-based psychological resilience scores (ie, residual scores) were computed for everyone by calculating the difference between actual and predicted distress score from this regression model. Resilience residual scores were inverted so that a positive value indicated greater psychological resilience (lower actual vs predicted score). By using this methodology, higher resilience scores are not attributed to an absence of stress or trauma exposure, but instead low psychological distress is relative to the level of exposure burden in the full sample. Figure 1 shows a histogram of the final calculated resilience residual scores for the sample.

Third, we conducted a multivariable hierarchical linear regression analysis in which standardized resilience residual scores were regressed onto sociodemographic and military characteristics (Step 1), psychiatric disorder and treatment history (Step 2), protective psychosocial characteristics (Step 3), and West Point-specific characteristics (Step 4) to determine factors that were independently associated with psychological resilience. To examine whether independent variables were moderated by gender, we incorporated interaction terms of each significant main effect × gender into this regression model. 29 Fourth, we conducted relative importance analyses to compute the relative variance in resilience scores that were The LEC was developed at the National Center for PTSD concurrently with the CAPS to assess exposure to potentially traumatic events. These events included natural disaster, physical assault, and transportation accident. The total number of life events personally experienced by the respondent were summed to yield a total count. Activity level compared to peers

Respondents were asked to rate their activity level compared to others of the same age and sex on a scale from 1 (much less active) to 5 (much more active). explained by significant independent variables. All analyses were conducted using IBM SPSS Statistics Version 26 and the relaimpo R package (R Core Team, 2015) to conduct the relative importance analyses. 36 Results Table 2 shows characteristics of the full sample and by gender. Table 3 shows the full sample response to reporting current PTSD (PCL-5), depression (PHQ-2), and anxiety (GAD-2) scores. It also shows reported personal experience with each individual exposure to lifetime adverse experiences (as defined above). Participants reported experiencing an average of 3.3 (SD = 2.5; range = 0-13) such events in their lifetimes. Table 4 shows results of a hierarchical linear regression model examining correlates of psychological resilience. The R 2 for the overall model was 0.39;

Step 1 (sociodemographic and military factors) R 2 = 0.05; Step 2 (psychiatric history and treatment) R 2 = 0.17, R 2 change = 0.13;

Step 3 (psychosocial factors and coping mechanisms) R 2 = 0.36, R 2 change = 0.18; and

Step 4 (West Point factors) R 2 = 0.39, R 2 change = 0.04.

Ten variables emerged as being independently associated with greater psychological resilience: the psychosocial factors of (a) social connectedness and (b) purpose in life; the health factors of (c) absence of history of lifetime psychiatric condition, and (d) absence of treatment with psychiatric medication; the character trait of (e) increased grit; the military experiences of (f) increased activity level compared to peers, (g) fewer reported negative perceptions of military experiences, and (h) greater time in service was associated with greater resilience in women; (i) the coping mechanisms of acceptance, and (j) coping with substance use having a negative correlation with resilience. Post hoc analysis of the negative perceptions of military experiences suggested that this factor was driven by the perceived negative consequences of a "drinking problem" (β = −.11, P < .001), "death and destruction" (β = −.10, P < .001), and "lost my good health" (β = −.07, P = .017).

Relative importance analysis of the significant correlates of psychological resilience revealed that the strongest correlates of psychological resilience were purpose in life (29.8% of relative variance explained [RVE]), fewer perceived negative experiences in the military (20.6% RVE), social support (9.6% RVE), and grit (9.5% RVE).

We additionally examined all significant predictors of resilience with a post hoc analysis by gender. Greater time in service is associated with greater resilience in women (β = 0.14, t = 3.79, P < .001) but not men (β = 0.04, t = 1.19, P = .23). None of the other interactions were significant, all P values > .10. 

To our knowledge, this study is the first to examine factors associated with psychological resilience in a nationally representative sample of West Point graduates. A notable strength of this investigation was access to and study of a sample of individuals extensively trained to be resilient who have high risk of exposure to stressful events. The assessment of psychological resilience used a discrepancy-based approach Percentages are of those who reported yes to a combat deployment that computes each participant's individual level of distress in relation to what is expected at the population level. This approach generates a measure of psychological resilience that spans the full-dimensional spectrum from high vulnerability to high resilience. Given previous criticisms that operationalizations of psychological resilience should not be limited to PTSD symptoms, we chose to employ a more comprehensive assessment of psychological distress that included PTSD, anxiety, and depressive symptoms. In addition, a wide range of psychosocial factors, character traits, health variables, military experiences, as well as coping strategies that could be linked to psychological resilience were measured and assessed. Results revealed that purpose in life, social support, and grit were most strongly associated with resilience. Report of fewer negative experiences in the military was also associated with resilience and, for women, greater time in service was correlated with resilience. Results of the current study suggest multiple factors contribute to the capacity to weather adversity. Importantly, these factors are modifiable and thus use of multimodal prevention and treatment efforts may be effective in maintaining and building psychological resilience for both men and women.

Purpose in life was most strongly associated with psychological resilience. Potential behavioral mechanisms underlying this association include a positive relationship between purpose in life and physical activity, internal locus of control, better sleep quality, better emotion regulation, and use of preventive health care services. [37] [38] [39] Interventions that may help enhance purpose in life for high-risk populations exposed to stress and trauma include using meaning-based therapies, such as logotherapy, and integration of meaning-and purpose-centered activities in other established psychotherapies, such as cognitive-behavioral therapy. [40] [41] [42] [43] Development of purpose in life also might lead to an increase in other protective factors, such as motivation to engage in social interactions. 37 Military service provides both subjective positive and negative experiences that influence veterans' mental health later in life. 44 For example, veterans who report more negative military experiences may be more likely to develop PTSD symptoms later in life and have increased odds of current suicidal ideation and current mental health disorders. 45, 46 Results of our study extend this work to suggest that reports of drinking problems, witnessing death and destruction, and worsening physical health may be linked to reduced psychological resilience. Although witnessing death and destruction as a negative consequence of military service may appear to be embedded in our trauma exposure calculation, the trauma exposure measure is based on whether exposure to an event occurred, not whether it is perceived as having a negative consequence in one's life. It is the perception of the event being negative that we found to be related to lower psychological resilience. Given the cross-sectional design of our study, however, we are unable to ascertain whether negative perceptions of reported events are influenced by current mental health difficulties, or if the endorsement of more negative effects drives risk for psychological distress and general maladaptive perceptions of one's life (eg relationships, finances, health). 46 Nevertheless, this finding underscores the importance of addressing negative mental and physical health consequences of perceived trauma, as well as screening for and treating current risky drinking behaviors and poor health in efforts to help promote resilience.

Social support was also strongly associated with psychological resilience. Greater perceptions of social support may help increase psychological resilience by promoting selfesteem, active coping strategies, a sense of control, evaluation of potentially stressful events as less threatening, and motivation to adopt healthfully and reduce risky behaviors. 1 Encouraging involvement in one's community, as well as community policies and programs that support and enhance connection by promoting safe neighborhoods, affordable housing, and public spaces for assembly and exercise are all methods of promoting and improving social support. 47 Of note, positive social support has been shown to activate the parasympathetic nervous system and brain regions implicated in the processing of safety cues and stimulate the release of oxytocin, which is known to have anxiolytic effects. 48, 49 Grit has 2 main components, perseverance of efforts and consistency of interest. 21, [50] [51] [52] The first component, perseverance of efforts is thought to overlap with the construct of resilience since it refers to maintaining goals even when obstacles are encountered. Some studies show grit is associated with a reduced tendency for suicide ideation and decreased burnout in doctors and surgical residents. [53] [54] [55] In studying West Point cadets, Duckworth and colleagues found that those who had higher grit at the entry to the academy were less likely to drop out of the first basic training summer than less gritty peers, even after controlling for SAT scores, high school class rank, and conscientiousness. 52 Recently, Duckworth et al. 56 also found that grit and physical ability in a cohort of West Point cadets were better predictors of 4-year graduation from the Academy than cognitive ability. Additionally, grit has been associated with resilience itself but, to our knowledge, this is only based on selfreported resilience scales, such as the Connor-Davidson Resilience Scale©. 57, 58 Our study adds to this literature by identifying a relationship between grit and psychological resilience using a resilience score measured on a continuum. This is an important identified relationship since grit is also a modifiable factor. Therapeutic interventions to promote a growth mindset and work on goal-setting and discovering one's passions may help increase grit. 59, 60 Results did not indicate gender differences in factors associated with resilience except for the greater time in service, which was associated with greater resilience in women only. [61] [62] [63] This is perhaps a result of women who stay in the military longer being those who have accommodated to the military environment and learned to cope and survive in a male-dominated hierarchical environment. 64 It is also possible that there are psychological vulnerabilities from leaving military service that are inherent to women only. One reason women are more likely to leave the service than men are due to family obligations, such as having children. Driven, gritty women who obtain training and education by attending West Point then no longer work or fill the role of a military officer may become more vulnerable to mental health issues later in life. This is perhaps due to a loss of purpose in life or career goals, whereas men who leave the military are more often pursuing a different career. For those who opt to leave the military and pursue a different career, female veterans often seek careers in similarly male-dominated fields and have reported difficulty integrating into the civilian workforce due to differences in dress, behavior (posture, assertiveness), identity issues, and disconnection from their civilian female counterparts. 64, 65 Efforts to support a smooth transition for women into civilian careers may alleviate these experiences, particularly regarding the unique challenges they may face.

Limitations of this study include the use of self-report measures, which may be subject to recall bias, although this is a similar possibility with clinician-administered scales. The response rate of the survey was also a limitation. However, with our sampling strategy of overrepresenting women, we achieved statistically significant results for gender comparisons; and, through age, class year, racial, and branch demographics for the population, we were able to achieve a representative sample of the targeted population. Although social support and grit appear to play a role in psychological resilience, the amount of variance explained by each was relatively low. Finally, given the cross-sectional design, we cannot establish temporal or causal associations. Consequently, it is unclear if the greater purpose in life, social support, and grit give rise to greater resilience or vice versa, or if these associations are bidirectionally linked over time. To date, all of the known studies that have employed a discrepancy based psychological resilience approach to operationalizing resilience have done so using cross-sectional data. 9, 10 Longitudinal studies employing prospective designs are needed to evaluate the application of a discrepancy-based approach and evaluate the role of flexible self-regulation and other time-varying factors in contributing to resilience. 66 

Taken together, results of this study demonstrate the utility of a novel dimensional approach to operationalize and identify factors associated with resilience in West Point graduates. Results revealed that greater purpose in life and fewer perceived negative experiences in the military, and to a lesser extent, social support and grit, all of which have been shown to be modifiable, were most strongly linked to resilience. 41, 43, 59, 60, [67] [68] [69] Findings lend themselves to consideration of assessing and building resilience for West Point graduates and individuals in other leadership roles and high-stress occupations. Notably, the approach to operationalizing and understanding resilience described in this paper can be applied to a broad range of stress/trauma-affected populations. For example, we considered both general and population-specific exposures (eg, count of traumas and combat exposure, respectively) and potential correlates (eg, purpose in life and perceptions of military service, respectively) of resilience in our analyses, as they were relevant to the study population. Studies of other stress and trauma-affected populations, such as first responders, might assess occupational and personal stressors (eg, knowing a colleague who died in the line of duty) and resilience-promoting factors (eg, perceived preparedness) that are specific to these populations and the evolving context of a stressful experience. One framework for conceptualizing potential factors associated with resilience is the PERMA model, which posits that positive emotion (P), engagement (E), relationships (R), meaning (M), and accomplishments (A) are core components of well-being. 70 Further research is needed to evaluate how factors that comprise these multidimensional componentsindividually and interactively-may contribute to resilience in various stress-and trauma-affected populations.

Another future direction is to examine the potential utility of a discrepancy-based approach to operationalizing resilience in measuring specific aspects of resilience, such as functional resilience (ie, maintaining a high level of functioning in the face of high psychological distress). Additional research is also needed to investigate biological factors in understanding underlying mechanisms associated with psychological resilience, evaluate longitudinal associations between resilience-promoting factors and resilience, and develop and test the efficacy of interventions to promote psychological resilience in populations at high risk of exposure to trauma and significant sources of stress.

Why are some individuals more resilient than others: the role of social support

Resilience: The science of mastering life's greatest challenges

Resilience as a translational endpoint in the treatment of PTSD

Intervention studies to foster resilience-A systematic review and proposal for a resilience framework in future intervention studies

The association of resilience on psychiatric, substance use, and physical health outcomes in combat trauma-exposed military service members and veterans

Psychological resilience in older US veterans: results from the national health and resilience in veterans study

Psychological resilience in US military veterans: a 2-year, nationally representative prospective cohort study

Trajectories of resilience and dysfunction following potential trauma: A review and statistical evaluation

The construct of resilience: A critical evaluation and guidelines for future work

cognitive/psychological traits and psychiatric resilience: A multivariate twin study

Resilience to traumatic stress in US military veterans: application of a novel classification approach in a nationally representative sample

Post-traumatic growth among veterans in the USA: results from the National Health and Resilience in Veterans Study

Resilience, sense of coherence, purpose in life and self-transcendence in relation to perceived physical and mental health among the oldest old

Religion, spirituality, and posttraumatic growth: A systematic review

Religiosity predicts posttraumatic growth following treatment in veterans with interpersonal trauma histories

Association between life purpose and mortality among US adults older than 50 years

Childhood sexual abuse as a risk factor for depression in women

Childhood maltreatment as a risk factor for adult cardiovascular disease and depression

Sex differences in the effect of childhood trauma on the clinical expression of early psychosis

PTSD treatment response and quality of life in women with childhood trauma histories

Grit: perseverance and passion for long-term goals

Gender differences among veterans deployed in support of the wars in Afghanistan and Iraq

Gender differences in posttraumatic stress disorder

Sex and gender differences in post-traumatic stress disorder: an update

Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research

The role of gender in moderating treatment outcome in collaborative care for anxiety

Gender differences in the effects of deployment-related stressors and predeployment risk factors on the development of PTSD symptoms in National Guard Soldiers deployed to Iraq and Afghanistan

Gender differences in traumatic experiences and mental health in active duty soldiers redeployed from Iraq and Afghanistan

The first women of West Point

Mental health and comorbidities in U.S. military members

Posttraumatic growth in Veterans of Operations Enduring Freedom and Iraqi Freedom

Requirements for Admission. 10 -Armed Forces 2011; Subtitle B -Army Part III -Training Chapter

Officer classification and the future of diversity among senior military leaders: A case study of the Army ROTC

Is worst-event trauma type related to PTSD symptom presentation and associated features?

Relative importance analysis: A useful supplement to regression analysis

Purpose in life is associated with a reduced risk of incident physical disability in aging US military veterans

Purpose in life and use of preventive health care services

Purpose in life and positive health outcomes among older adults

Man's Search for Meaning; an Introduction to Logotherapy: Of From Death-camp to Existentalism

Logotherapy as an adjunctive treatment for chronic combat-related PTSD: A meaning-based intervention

Meaning-centered counseling: A cognitive-behavioral approach to logotherapy

Logotherapy can enrich cognitive behavioral therapy practice

Combat experience and emotional health: Impairment and resilience in later life

Vulnerability and resilience to combat exposure: Can stress have lifelong effects?

Association between perceptions of military service and mental health problems in a nationally representative sample of United States military veterans

How does social support enhance resilience in the trauma-exposed individual?

Social ties and health: a social neuroscience perspective

Oxytocin and stress-related disorders: neurobiological mechanisms and treatment opportunities

Much ado about grit: A meta-analytic synthesis of the grit literature

All that glitters is not grit: Three studies of grit in university students

Development and validation of the short grit scale (Grit-S)

Stability amidst turmoil: Grit buffers the effects of negative life events on suicidal ideation

The relationship between grit and resident well-being

Grit and burnout in UK doctors: a cross-sectional study across specialties and stages of training

Cognitive and noncognitive predictors of success

Psychometric analysis and refinement of the connor-davidson resilience scale (CD-RISC): Validation of a 10-item measure of resilience

Review of grit and resilience literature within health professions education

Building grit: The longitudinal pathways between mindset, commitment, grit, and academic outcomes

The development of grit and growth mindset during adolescence

Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of US OEF/OIF veterans

Gender differences among veterans deployed in support of the wars in Afghanistan and Iraq

Gender differences in the impact of warfare exposure on self-rated health

Career development for women veterans: Facilitating successful transitions from military service to civilian employment

Being a female veteran: A grounded theory of coping with transitions

The resilience paradox

Preventing loneliness and social isolation: interventions and outcomes. Social Care Institute for Excellence London

Reducing loneliness amongst older people: a systematic search and narrative review

Interventions targeting social isolation in older people: a systematic review

Flourish: a visionary new understanding of happiness and well-being

Psychometric properties of the life events checklist

The posttraumatic stress disorder checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation

An ultra-brief screening scale for anxiety and depression: the PHQ-4

The multidimensional scale of perceived social support

The purpose in life test-short form: development and psychometric support

The Duke University Religion Index (DUREL): a five-item measure for use in epidemological studies

You want to measure coping but your protocol's too long: Consider the brief cope

International physical activity questionnaire: 12-country reliability and validity

The authors would like to acknowledge the assistance of the West Point Association of Graduates for access to population data and email database of graduates for recruitment of participants. 

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The author Southwick wishes to declare he receives royalties for one of the cited references: Resilience: The science of mastering life's greatest challenges. The authors Thomas, Pietrzak, Nguyen, Ryan, and Mazure report no financial affiliation or other relationship relevant to the subject of this manuscript.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article. This research was supported by an anonymous donation to fund $500 towards a drawing of gift cards ($100 each) for a random selection of (5) participants. Pietrzak's effort on this project was supported by the US Department of Veterans Affairs National Center for PTSD.

The study was approved by the Yale University Institutional Review Board and reviewed by the West Point human protections committee.

Melissa M. Thomas, MD https://orcid.org/0000-0003-4636-0901 Dana R. Nguyen, MD https://orcid.org/0000-0003-3506-9350