Resilience facilitates adjustment through greater psychological flexibility among Iraq/Afghanistan war veterans with and without mild traumatic brain injury

Abstract

Objectives: Although many Iraq/Afghanistan warzone veterans report few problems with adjustment, a substantial proportion report debilitating mental health symptoms and functional impairment, suggesting the influence of personal factors that may promote adjustment. A significant minority also incur warzone-related traumatic brain injury (TBI), the majority of which are of mild severity (mTBI). We tested direct and indirect pathways through which a resilient personality prototype predicts adjustment of warzone veterans with and without mTBI over time.

Method: A sample of 264 war veterans (181 men) completed measures of lifetime and warzone-related TBIs, personality traits, psychological adjustment, quality of life, and functional impairment. Social support, coping, and psychological flexibility were examined as mediators of the resilience-adjustment relationship. Instruments were administered at baseline, 4-, 8-, and 12-month assessments. Structural equation models accounted for combat exposure and response style.

Results: Compared with a nonresilient personality prototype, a resilient prototype was directly associated with lower PTSD, depression, and functional disability, and higher quality of life at all time-points. Warzone mTBIs frequency was associated with higher scores on a measure of functional disability. Indirect effects via psychological flexibility were observed from personality to all outcomes, and from warzone-related mTBIs to PTSD, depression, and functional disability, at each time-point.

Conclusions: Several characteristics differentiate veterans who are resilient from those who are less so. These findings reveal several factors through which a resilient personality prototype and the number of mTBIs may be associated with veteran adjustment. Psychological flexibility appears to be a critical modifiable factor in veteran adjustment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Figure 1.

Resilient (n=138) and non-resilient (n=126) personality prototypes among veterans based on NEO-FFI z scores.

Figure 2.

Saturated a priori model of personality prototypes, TBI and mediating characteristics predicting adjustment over 12-months. Note: The covariates were assumed to have direct effects on TBI variables, personality type, mediators and outcomes. Mediators were allowed to correlate with each other. Outcomes were allowed to correlated with each other over time. FCES = Full Combat Exposure Scale; MC = Marlowe-Crowne Social Desirability Scale; NTBI = Lifetime number of traumatic brain injuries including civilian and military; PTA = Worst posttraumatic amnesia rating; LOC = Worst loss of consciousness rating; NTBI (warzone) = Number of TBIs during post-9/11 warzone deployment; BRS = Brief Resilience Scale; PDSS = Postdeployment Social Support Scale; AAQ-II = Acceptance and Action Questionnaire-II; B-COPE Action = Brief COPE Active coping factor score; B-COPE Avoidant = Brief COPE Avoidant coping factor score; PCL-M = PTSD Checklist-Military Version; BDI-II = Beck Depression Inventory-II; QLS = Quality of Life Scale; WHODAS = World Health Organization Disability Assessment Scale 2.0.

Figure 3a.

Path model of personality prototype, traumatic brain injury variables, and mediating characteristics predicting PTSD Checklist-Military Version (PCL-M) scores across four time points. R² = 52.4% – 72.4% Note: Only statistically significant direct effects denoted by using standardized path coefficients were shown. The covariates were assumed to have direct effects on TBI variables, personality type, mediators and outcomes. Mediators were allowed to correlate with each other. Outcomes were allowed to correlate with each other over time. FCES = Full Combat Exposure Scale; MC = Marlowe-Crowne Social Desirability Scale; NTBI = Lifetime number of traumatic brain injuries including civilian and military; PTA = Worst posttraumatic amnesia rating; LOC = Worst loss of consciousness rating; NTBI (warzone) = Number of TBIs during post-9/11 warzone deployment; BRS = Brief Resilience Scale; PDSS = Postdeployment Social Support Scale; AAQ-II = Acceptance and Action Questionnaire-II; B-COPE Action = Brief COPE Active coping factor score; B-COPE Avoidant = Brief COPE Avoidant coping factor score.

Figure 3b.

Path model of personality prototype, traumatic brain injury variables, and mediating characteristics predicting Beck Depression Inventory-II (BDI-II) scores across four time points. R² = 47.4% – 68.7% Note: Only statistically significant direct effects denoted by using standardized path coefficients are shown. The covariates were assumed to have direct effects on TBI variables, personality type, mediators and outcomes. Mediators were allowed to correlate with each other. Outcomes were allowed to correlate with each other over time. FCES = Full Combat Exposure Scale; MC = Marlowe-Crowne Social Desirability Scale; NTBI = Lifetime number of traumatic brain injuries including civilian and military; PTA = Worst posttraumatic amnesia rating; LOC = Worst loss of consciousness rating; NTBI (warzone) = Number of TBIs during post-9/11 warzone deployment; BRS = Brief Resilience Scale; PDSS = Postdeployment Social Support Scale; AAQ-II = Acceptance and Action Questionnaire-II; B-COPE Action = Brief COPE Active coping factor score; B-COPE Avoidant = Brief COPE Avoidant coping factor score.

Figure 3c.

Path model of personality prototype, traumatic brain injury variables, and mediating characteristics predicting Quality of Life Scale (QLS) scores across four time points. R² = 39.2% – 59.3% Note: Only statistically significant direct effects denoted by using standardized path coefficients are shown. The covariates were assumed to have direct effects on TBI variables, personality type, mediators and outcomes. Mediators were allowed to correlate with each other. Outcomes were allowed to correlate with each other over time. FCES = Full Combat Exposure Scale; MC = Marlowe-Crowne Social Desirability Scale; NTBI = Lifetime number of traumatic brain injuries including civilian and military; PTA = Worst posttraumatic amnesia rating; LOC = Worst loss of consciousness rating; NTBI (warzone) = Number of TBIs during post-9/11 warzone deployment; BRS = Brief Resilience Scale; PDSS = Postdeployment Social Support Scale; AAQ-II = Acceptance and Action Questionnaire-II; B-COPE Action = Brief COPE Active coping factor score; B-COPE Avoidant = Brief COPE Avoidant coping factor score.

Figure 3d.

Path model of personality prototype, traumatic brain injury variables, and mediating characteristics predicting World Health Organization Disability Assessment Schedule 2.0 (WHODAS) scores across four time points. R² = 40.8% – 58.1% Note: Only statistically significant direct effects denoted by using standardized path coefficients are shown. The covariates were assumed to have direct effects on TBI variables, personality type, mediators and outcomes. Mediators were allowed to correlate with each other. Outcomes were allowed to correlate with each other over time. FCES = Full Combat Exposure Scale; MC = Marlowe-Crowne Social Desirability Scale; NTBI = Lifetime number of traumatic brain injuries including civilian and military; PTA = Worst posttraumatic amnesia rating; LOC = Worst loss of consciousness rating; NTBI (warzone) = Number of TBIs during post-9/11 warzone deployment; BRS = Brief Resilience Scale; PDSS = Postdeployment Social Support Scale; AAQ-II = Acceptance and Action Questionnaire-II; B-COPE Action = Brief COPE Active coping factor score; B-COPE Avoidant = Brief COPE Avoidant coping factor score.