Research Article DEVELOPMENT OF A NEW RESILIENCE SCALE: THE CONNOR-DAVIDSON RESILIENCE SCALE (CD-RISC) Kathryn M. Connor, M.D.,n and Jonathan R.T. Davidson, M.D. Resilience may be viewed as a measure of stress coping ability and, as such, could be an important target of treatment in anxiety, depression, and stress reactions. We describe a new rating scale to assess resilience. The Connor-Davidson Resilience scale (CD-RISC) comprises of 25 items, each rated on a 5-point scale (0���4), with higher scores reflecting greater resilience. The scale was administered to subjects in the following groups: community sample, primary care outpatients, general psychiatric outpatients, clinical trial of generalized anxiety disorder, and two clinical trials of PTSD. The reliability, validity, and factor analytic structure of the scale were evaluated, and reference scores for study samples were calculated. Sensitivity to treatment effects was examined in subjects from the PTSD clinical trials. The scale demonstrated good psychometric properties and factor analysis yielded five factors. A repeated measures ANOVA showed that an increase in CD-RISC score was associated with greater improvement during treatment. Improvement in CD-RISC score was noted in proportion to overall clinical global improvement, with greatest increase noted in subjects with the highest global improvement and deterioration in CD-RISC score in those with minimal or no global improvement. The CD- RISC has sound psychometric properties and distinguishes between those with greater and lesser resilience. The scale demonstrates that resilience is modifiable and can improve with treatment, with greater improvement corresponding to higher levels of global improvement. Depression and Anxiety 18:76���82, 2003. & 2003 Wiley-Liss, Inc. Key words: resilience stress coping wellbeing posttraumatic stress disorder anxiety depression INTRODUCTION Resilience embodies the personal qualities that enable one to thrive in the face of adversity. Research over the last 20 years has demonstrated that resilience is a multidimensional characteristic that varies with con- text, time, age, gender, and cultural origin, as well as within an individual subjected to different life circum- stances [e.g., Garmezy, 1985 Garmezy and Rutter, 1985 Rutter et al., 1985 Seligman and Csikszentmi- halyi, 2000 Werner and Smith, 1992]. One theory for this variability was developed by Richardson and colleagues, who proposed the following resiliency model [Richardson et al., 1990 Richardson, 2002]. Beginning at a point of biopsychospiritual balance (������homeostasis������), one adapts body, mind, and spirit to current life circumstances. Internal and external stressors are ever-present and one���s ability to cope with these events is influenced by both successful and unsuccessful adaptations to previous disruptions. In some situations, such adaptations, or protective DEPRESSION AND ANXIETY 18:76���82 (2003) Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina Contract grant sponsor: Smith Kline Beecham Contract grant sponsor: Pfizer Pharmaceuticals Contract grant sponsor: Pure World Botanicals, Inc. Contract grant sponsor: Organon Con- tract grant sponsor: NIH Contract grant number: R01 MH56656- 01A1 nCorrespondence to: Dr. Connor, Box 3812, DUMC, Durham, NC 27710. E-mail: kathryn.connor@duke.edu Received for publication 15 September 2002 Accepted 1 April 2003 DOI: 10.1002/da.10113 Published online in Wiley InterScience (www.interscience.wiley.com). & & 2003 WILEY-LISS, INC.

factors, are ineffective, resulting in disruption of the biopsychospiritual homeostasis. In time, response to this disruption is a reintegrative process, leading to one of four outcomes: (1) the disruption represents an oppor- tunity for growth and increased resilience, whereby adaptation to the disruption leads to a new, higher level of homeostasis (2) a return to baseline homeostasis, in an effort to just get past or beyond the disruption (3) recovery with loss, establishing a lower level of home- ostasis or 4) a dysfunctional state in which maladaptive strategies (e.g., self-destructive behaviors) are used to cope with stressors. Resilience may thus also be viewed as measure of successful stress-coping ability. The clinical relevance of resilience and related constructs has been noted previously. Maddi and Khoshaba theorized that hardiness was an index of mental health [Maddi and Khoshaba, 1994] and recent data has supported this hypothesis [Ramanaiah et al., 1999]. Tsuang [2000] has emphasized the substantial clinical implications that follow a better understanding of the forces that mould resilience. With regard to trauma and posttraumatic stress disorder (PTSD), it has been shown that hardiness contributes to protec- tion against developing chronic PTSD after combat [King et al., 1998 Waysman et al., 2001]. The growing focus on health promotion and well- being, shifting emphasis away from pathology and problem-orientation, provides an opportunity to revisit the role of resilience in health. Yet there is relatively little awareness about resilience or its importance in clinical therapeutics. Conventionally, therapeutic trials have focused more heavily on measuring morbidity, although quality of life elements are now included in many trials. A number of scales have been developed to measure resilience [Bartone et al., 1989 Wagnild and Young, 1993] or aspects of resilience [e.g., hardiness: Hull et al., 1987, Kobasa, 1979 perceived stress, Cohen et al., 1983]. However, these measures have neither been widely used nor applied to specific populations [Carlson, 2001 Mosack, 2002] and thereby lack generalizability. Of striking note, a textbook of psy- chiatric measures recently published by the American Psychiatric Association contains not a single resilience measure [American Psychiatric Association, 2000]. The need for well-validated measures of resilience that are simple to use is thus evident. While several scales have been developed, they have not gained wide acceptance and no one scale has established primacy. With these considerations in mind, the Connor- Davidson Resilience Scale (CD-RISC) was developed as a brief self-rated assessment to help quantify resilience and as a clinical measure to assess treatment response. METHODS SCALE DEVELOPMENT We recently became interested in the concept of resilience as being relevant to treatment outcome in anxiety, depression, and stress reactions. This interest arose in part from a finding that fluoxetine produced greater therapeutic benefit on stress coping than placebo in PTSD [Connor et al., 1999]. Furthermore, in reviewing the account of Sir Edward Shackleton���s heroic expedition in the Antarctic in 1912 [Alexander, 1998], it was noted that the expedition���s leader possessed many personal characteristics compatible with resilience and that this may perhaps have contributed to the successful survival of each member of the expedition in the face of overwhelming odds. Together, these observations prompted the authors to undertake the development of a short self-rated resilience measure. The content of the scale was drawn from a number of sources. From Kobasa���s work with the construct of hardiness [Kobasa, 1979], items reflecting control, commitment, and change viewed as challenge were included. The following features were drawn from Rutter���s work [Rutter, 1985]: developing strategy with a clear goal or aim, action orientation, strong self- esteem/confidence, adaptability when coping with change, social problem solving skills, humor in the face of stress, strengthening effect of stress, taking on responsibilities for dealing with stress, secure/stable affectional bonds, and previous experiences of success and achievement (these last two features may reflect the underpinnings of resilience). From Lyons [1991], items assessing patience and the ability to endure stress or pain were included. Lastly, from Shackleton���s experi- ences, it was noted that the role of faith and a belief in benevolent intervention (������good luck������) were likely important factors in the survival of the expedition, suggesting a spiritual component to resilience. Table 1 summarizes the salient features of resilience. With the above considerations, the CD-RISC was constructed, with the following goals in mind: to develop a valid and reliable measure to quantify TABLE 1: Characteristics of resilient people Reference Characteristic Kobasa, 1979 View change or stress as a challenge/opportunity Kobasa, 1979 Commitment Kobasa, 1979 Recognition of limits to control Rutter, 1985 Engaging the support of others Rutter, 1985 Close, secure attachment to others Rutter, 1985 Personal or collective goals Rutter, 1985 Self-efficacy Rutter, 1985 Strengthening effect of stress Rutter, 1985 Past successes Rutter, 1985 Realistic sense of control/having choices Rutter, 1985 Sense of humor Rutter, 1985 Action oriented approach Lyons, 1991 Patience Lyons, 1991 Tolerance of negative affect Rutter, 1985 Adaptability to change Current Optimism Current Faith Research Article: Resilience Scale: (CD-RISC) 77