5 Graduate Student Journal of Psychology Spring 2024 - Vol. 22 Copyright 2024 by the Department of Counseling and Clinical Psychology Teachers College, Columbia University Resilience and Psychological Distress in Genetic Testing for Alzheimer's Disease The landscape of preventative genetic testing is continuously expanding, providing insights into the likelihood of developing or transmitting genetic disor- ders. This form of testing holds apparent significance: offering the advantage of foreknowledge about genetic diseases prior to the manifestation of symptoms, facil- itating the diagnosis of various conditions, and receiv- ing information pertaining to the potential transmis- sion of genetic disorders to offspring (Khoury et al., 2006). Within Alzheimer's disease and related demen- tias, a focal point of investigation lies in genetic testing. Advanced technology is now available to analyze ge- netic makeup, facilitating the identification of specific genes associated with the onset of Alzheimer's disease. Consequently, some individuals are interested in pro- curing their genetic results (Cutler & Hodgson, 2003). As genetic testing advances and refines, its accessibil- ity is anticipated to expand, granting individuals the choice of accessing information about their suscepti- bility to Alzheimer's disease and related dementias. Ethical considerations stemming from the acquisition of potential symptomatology knowledge encompass issues of hereditary transmission, lifestyle adjust- ments, and future life planning (Roberts et al., 2003). Alongside the benefits of genetic testing, there are potential ramifications for those who opt to acquire genetic information, notably an increase in psycholog- ical distress. Psychological distress is characterized by a spectrum of stress-related symptoms encompassing anxiety, tension, and depression, significantly impact- ing overall well-being (Gooding et al., 2006). In the context of discovering that one is a carrier of an Alz- heimer’s disease gene, individuals may commonly be confronted with uncertainties regarding the timing and potential outcomes of their condition, thus in- tensifying psychological distress (Galluzzi et al., 2022). Given that Alzheimer's disease and related demen- tias involve irreversible brain degeneration and lack definitive curative treatments, the absence of viable long-term remedies could lead to distress among in- dividuals experiencing cognitive impairment or a de- mentia diagnosis (Cutler & Hodgson, 2003). There- fore, receiving genetic information about Alzheimer's disease has the potential to induce substantial psy- chological distress (Bookherimer & Burggren, 2009). Moreover, chronic stress has been shown to ex- ert a detrimental impact on Alzheimer's disease itself. Research suggests that sustained stress can accelerate the progression of Alzheimer’s disease, leading to in- creased neurodegeneration and the worsening of cog- nitive and behavioral symptoms in affected individ- uals (Justice, 2018). This complex interplay between stress and Alzheimer’s disease underscores the need for comprehensive interventions aimed at addressing both the psychological well-being of patients and the biological factors contributing to disease progression. Though the psychological impact of receiving a diagnosis for an incurable disease is apparent, the do- Alicia Burgei Department of Psychology, Tiffin University The relationship between resilience and psychological distress resulting from genetic testing for Alzheimer’s disease among non-cognitively impaired individuals is examined in this study. Preventative genetic testing determines the likelihood of developing or passing on genetic disorders. However, receiving genetic information, especially regarding incurable diseases like Alzheimer’s disease, can lead to significant psychological distress. Resilience, the ability to cope with adversity and recover quickly, is considered a protective factor against psychological distress. The purpose of this study is to investigate whether higher levels of resilience are associated with lower psychological distress from genetic testing for Alzheimer’s disease and to determine if having a familial history of Alzheimer’s disease influences this re- lationship. An online cross-sectional survey was conducted among 181 non-cognitively impaired participants (43.6% Male; 54.1% Female; Mage=38.1 [13.9]) using the Impact of Genetic Testing for Alzheimer’s Disease (IGT-AD) scale and the Brief Resilience Scale (BRS), along with a question about family history of Alzheimer’s disease. The results indicated a significant negative correlation between resilience and psychological distress, suggesting that individuals with higher resilience experienced lower distress related to genetic testing. However, family history did not mediate the relationship, meaning the protective effect of resilience was consistent regardless of familial risk. These findings have implications for developing targeted support services and resilience-based interventions to help individuals cope with the emotional impact of genetic testing for Alzheimer’s disease. Further research could explore other potential pro- tective factors and examine the long-term impact of genetic testing results on psychological well-being and behavior. Keywords: resilience, psychological distress, genetic testing, Alzheimer’s disease 6 BURGEI main of potentially protective factors remains less ex- plored. Resilience is a pivotal protective factor against psychological distress (Garmezy, 1991). Resilience, characterized by the ability to withstand or recover quickly from distress, has an established inverse cor- relation with psychological distress (Yasien et al., 2016). Norman Garmezy introduced the resilience theory to understand how individuals who face adversities and risk exposure can develop normally and become healthy adults (Garmezy, 1991). This theory postu- lates that resilience entails rebounding from emotion- al distress and maintaining adaptive behavior despite threats and adversities to an individual's well-being. Resilience has been shown to impact the adjust- ment to genetic testing results with hereditary diseas- es, including cancers (Ho et al., 2010). Psychological distress from genetic testing is impacted by the se- verity of the disease, perceived risk, ability to control the disease, and availability of treatments (Oliveri et al., 2018). Analogous to cancer, Alzheimer's disease significantly affects quality of life and psychosocial well-being and often necessitates long-term care or interventions (Oliveri et al., 2018). Hence, further exploration is required to unravel the interplay be- tween resilience and psychological distress from ge- netic testing, particularly in Alzheimer's disease. Moreover, the influence of resilience on psycho- logical distress may not be uniform across all indi- viduals. Family history, which signifies whether an individual has a familial predisposition to Alzheimer's disease, has the potential to influence this relation- ship. A family history of a disease, particularly one with a genetic component like Alzheimer's disease, can significantly heighten psychological distress (Liu & Cao, 2014). It leads to increased awareness of one's susceptibility, fostering stress and anxiety, as individu- als become more concerned about their own risk and the possibility of transmitting the condition to their descendants (Roberts et al., 2003). Furthermore, fam- ily history can impose a perceived genetic "inheritance burden" on individuals, leading to guilt and concern about implications for their loved ones or future gen- erations (James et al., 2006). While family history can increase the risk of developing Alzheimer's disease (Liu & Cao, 2014), its role in the context of resilience and psychological distress remains underexplored. An understanding of the psychological impact of genetic testing, particularly in the Alzheimer's context, is beneficial in identifying individuals at heightened risk of psychological distress and in devising additional coping strategies (Chung et al., 2009). Resilience-based interventions aimed at strengthening an individual's re- silience, thereby mitigating distress, and at promoting emotional well-being hold the potential to significant- ly enhance the quality of life for individuals afflicted by neurocognitive disorders. However, more information is needed to understand how to effectively introduce resilience interventions (Wang et al., 2021), specifical- ly in the context of receiving genetic testing results. Purpose The purpose of this study is to examine the rela- tionship between resilience and psychological distress from genetic testing for Alzheimer’s disease among non-cognitively impaired individuals, hereafter re- ferred to as ‘unimpaired.’ Drawing from resilience theory, which posits that protective factors mitigate the adverse consequences of risk exposure (Garmezy, 1992), it is hypothesized that individuals with high- er levels of resilience will experience lower levels of psychological distress when considering genetic test- ing for Alzheimer's disease. This association rests on the premise that individuals exhibiting higher resilience levels will experience lower levels of emo- tional and behavioral challenges, such as depression, anxiety, and stress (Yasien et al., 2016), compared to their counterparts with lower resilience levels. Furthermore, family history is hypothesized to mediate the interplay between resilience and psy- chological distress. Instances of psychological dis- tress, including anxiety, depression, and disease-spe- cific distress, tend to intensify in the presence of a family history of particular diseases (Liu & Cao, 2014). Family history is projected to influence the strength of the relationship of resilience as a posi- tive adaptation to psychological distress, given that a familial history of Alzheimer's disease is likely to amplify the psychological distress experienced by par- ticipants contemplating genetic testing for the disease. The intent of the study is to answer two key research questions: 1. Do variations in the Impact of Genetic Testing for Alzheimer's Disease (IGT-AD) scores relate to levels of resilience among unimpaired partici pants? 2. Does the presence of a family history of Alzhei mer’s disease influence or mediate this relationship? 7 RESILIENCE AND PSYCHOLOGICAL DISTRESS This study aims to recruit participants to com- plete a survey consisting of the IGT-AD survey, Brief Resilience Scale, and a query regarding a family his- tory of Alzheimer’s disease. The IGT-AD (Appendix 1) was created to evaluate the nature of genetic infor- mation and examine the impact of Alzheimer’s dis- ease risk assessment (Chung et al., 2009). The survey will measure the adverse effects of participants receiv- ing genetic information about Alzheimer’s disease. The Brief Resilience Scale (Appendix 2) will assess the perceived ability to bounce back or recover from stress (Smith et al., 2008). The variables, psychologi- cal distress from Alzheimer's disease genetic testing and resilience, will be assessed for a relationship and will determine if family history impacts the relation- ship. The findings hold significant implications for discerning susceptibility to psychological distress re- lated to genetic testing and understanding the role of resilience in counteracting these psychological effects. Method Participant Recruitment and Selection To address the research question, a cross-section- al survey was conducted online, leveraging the bene- fits of prompt participant data collection without the need for in-person administration, which aligns with the study’s focus on obtaining a snapshot of charac- teristics at a specific moment. This research project underwent rigorous ethical review and received In- stitutional Review Board (IRB) approval from Tiffin University, ensuring the protection and well-being of all participants involved. Prior to involvement in the study, participants were required to complete an informed consent which provided comprehensive in- formation about the research objectives, procedures, potential risks, benefits, and confidentiality measures. Due to the convenience of online data collection, the internet survey platform, Prolific, was used for participant recruitment, with the study population of interest being cognitively unimpaired individuals. The survey obtained a study sample of participants who are not cognitively impaired or experiencing memory concerns through exclusion criteria. Par- ticipants who answered “yes” to the initial question regarding memory concerns and cognitive impair- ment: “Are you currently experiencing cognitive im- pairment or concerns with your memory and think- ing?”, were disqualified from the study. The survey was a convenience sample as the Prolific platform fills study places on a first-come, first-served basis and was distributed to all available participants. Participants were pre-screened for English as their primary lan- guage, and an inclusion criterion was implemented to obtain participants only from the United States. Sample Size Determination A power analysis was conducted using G*Pow- er to determine the appropriate sample size for the expected statistical analyses. For multiple regression (f2=.15, 80% power, α=.05) a minimum sample size of 82 and 68 participants, respectively, is required to yield meaningful results. The study aimed to recruit approximately 200 eligible participants to complete the survey, accounting for the number of partici- pants deemed ineligible due to the initial question regarding memory concerns or cognitive impair- ment and their incomplete survey completion. A to- tal of 231 participants initiated involvement in the study, and 50 participants were disqualified from the study due to the inclusion criteria. The sample size consisted of 181 responses with an average survey completion time of three minutes. Participants who completed the entirety of the survey were reward- ed $0.40 as an appreciation of their time and effort. Participant Demographics A total of 251 participants were presented with the survey, 181 met the inclusion criteria and com- pleted the entirety of the survey. The sociodemo- graphic characteristics are reported in Table 1. The sample consisted of 98 females (54.1%), 79 males (43.6%), and four non-binary participants (2.2%). Participants’ ages range from 19 to 73 years, with a mean age of 38.1 years (SD = 13.9). Regarding edu- cational attainment, 1 participant (0.6%) had some high school education, 23 participants (12.7%) had completed high school or equivalent, 63 participants (34.8%) had some college education, 75 participants (41.4%) held a bachelor’s degree, and 19 partici- pants (10.5%) held a graduate or professional degree. Survey Design The survey consisted of a one-group design with a two-variable comparison of psychological distress from Alzheimer’s disease genetic testing and resil- ience. Google Forms was used to generate a survey consisting of the preliminary question regarding current cognitive impairment, two embedded scales, a question regarding family history of Alzheimer’s 8 BURGEI disease: “Do you have a history of Alzheimer’s dis- ease in your family?” (Questionnaire 1), and demo- graphic questions (Questionnaire 1). The study items were piloted among five participants to determine the appropriateness and consistency of the items. Description of Scales Impact of Genetic Testing for Alzheimer’s Dis- ease Scale. The first scale, Impact of Genetic Testing for Alzheimer’s Disease (IGT-AD; Appendix 1), as- sessed the dependent variable, psychological distress from receiving Alzheimer’s disease genetic testing (Chung et al., 2009). The IGT-AD scale was devel- oped to accurately assess the psychological distress as- sociated with genetic testing for Alzheimer's disease. While existing risk assessment scales predominantly focus on measuring depression and anxiety (Chung et al., 2009), the IGT-AD scale was formulated to gauge the psychological impact of genetic susceptibility to Alzheimer's disease, incorporating insights from oth- er genetic testing impact assessment scales (Cella et al., 2002). This instrument is designed for clinical and research applications, providing a concise self-report measure of the psychological impact of genetic sus- ceptibility to Alzheimer's disease (Chung et al., 2009). This 16-item scale used a 4-point response scale where 0 was “strongly disagree,” and 5 was “strongly agree.” The total score ranges from 0-80, with higher scores reflecting greater psychological distress related to Alzheimer’s disease genetic testing (Chung et al., 2009). In their study, Chung et al. (2009) reported a mean of 16.9 with a standard deviation of 9.9, serv- ing as a reference point for interpretation, along with a Cronbach’s α of 0.82 for the scale. The IGT-AD was assessed for construct validity by comparing the final scale to other established psychometric scales, includ- ing the Impact of Event Scale (IES), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Beck Anxiety Inventory (BAI). Using Spearman’s correlations, the final scale was positively correlated with all the psychometric scales indicating convergent validity (Chung et al., 2009). The assessment results suggest that the IGT-AD is a valid and reliable scale that may be a more useful and sensitive tool in measur- ing psychological distress specific to Alzheimer’s dis- ease genetic testing than other generalized mood scales. Brief Resilience Scale. The second scale, the 6-item Brief Resilience Scale (BRS; Appendix 2), was used to measure the independent variable, resilience, or the perceived ability to bounce back or recover from stress (Smith et al., 2008). This 6-item scale used a 5-point response scale where 0 was “strongly dis- agree,” and 5 was “strongly agree.” The total score ranges from 0-30, with higher scores reflecting great- er resilience (M=21.18-23.88, SD=4.08-5.1; Smith et al., 2018). Smith et al. (2018) reported Cronbach’s α of 0.80-0.91 for the scale. The BRS was assessed for convergent validity and was positively correlat- ed with resilience measures, including optimism, social support, and life purpose, and was negatively correlated with pessimism and negative interactions (Smith et al., 2008). The assessment results indicate that BRS is an adequate measure of resilience with good internal consistency and test-retest reliability. Reliability and Validity in the Current Dataset To ensure the reliability and validity of the mea- surement instruments in the current dataset, an analysis of internal consistency was conducted using Cronbach's alpha. The values for Cronbach's alpha in our dataset, demonstrating a high level of internal consistency (α= .82 for IGT-AD and α= .94 for BRS), were found to be consistent with previous research (Chung et al., 2009; Smith et al., 2018), affirming the instruments' sustained reliability. Additionally, the content validity of the scales, which assess the intend- ed constructs, was confirmed as the items were adapt- ed from previous studies with established validity. Data Screening and Preliminary Assumptions Statistical analyses were performed using the SPSS 28.0 statistical software. The data met the as- sumptions for multiple regression analysis: (a) one continuous independent variable (IGT-AD Total Scores), one continuous dependent variable (BRS To- tal Scores), and one dichotomous mediator variable (family history) , (b) independent observations, (c) a linear relationship exists between the independent and dependent variables, (d) homoscedasticity is present, (e) no multicollinearity, (f) no outliers, and (g) the residuals are normally distributed. A Durbin-Wat- son statistic was conducted to support the inde- pendence of residuals (DW = 1.743). Standardized residuals indicated approximately normally distrib- uted errors, as did the normal P-P plot of standard- ized residuals. Tests for multicollinearity showed no concern (BRS total scores, Tolerance = .994, VIF = 1.006; Family history, Tolerance = .994, VIF =1.006). In order to explore the potential mediating effect 9 RESILIENCE AND PSYCHOLOGICAL DISTRESS of family history on the relationship between psy- chological distress and resilience, a mediator analysis using regression was applied. In the mediator anal- ysis, psychological distress and resilience are defined as the dependent and independent variables, respec- tively, while family history is defined as the media- tor to determine if family history impacts the rela- tionship. The PROCESS Macro Model 4 for SPSS was utilized to apply a bias-correct non-parametric bootstrapping technique with 5000 resamples to esti- mate family history’s direct, indirect, and total effects (Preacher & Hayes, 2008). All assumptions for the mediator analysis using regression analysis were met. Results Descriptive Statistics The survey's descriptive statistics are reported in Table 2. The sample contained 52 participants with a family history of Alzheimer's disease (28.7%) and 129 participants without (71.3%). No family history was coded as 0, and family history was reported as 1 with a reported mean of .287 (SD = .454). The total scores of the IGT-AD scale ranged from 1 to 72, with a mean score of 34.3 (SD = 11.8), indicating moderate psychological distress related to Alzheimer's disease ge- netic testing for the sample. The total score of the BRS scale ranged from 6 to 30, with a mean score of 19.8 (SD = 5.4), indicating a moderately resilient sample. Statistical Analyses Multiple Regression Analysis A multiple regression analysis was performed to investigate the relationship between psychological distress from Alzheimer’s disease-related genetic test- ing (IGT-AD scores) and resilience (BRS scores). The model, incorporating BRS scores as the independent variable and IGT-AD scores as the dependent variable, yielded a significant negative association (Figure 1). The multiple correlation coefficient (R) was 0.415, indicat- ing a moderate correlation between the predicted and observed values of IGT-AD scores and the predictor variable. The regression model, involving BRS scores, accounted for 17.22% of the variance in IGT-AD scores (R² = .172, F(2,175) = 16.057, p < 0.001). The unstandardized coefficient for BRS scores was -0.829 (p < 0.001), indicating that, for each unit increase in BRS scores, IGT-AD scores decreased by 0.829 units. Covariate Analysis To assess the potential influence of covariates on the relationship between BRS and IGT-AD scores an analysis of the covariates, including age, gender, and education was conducted. Education level emerged as a significant predictor (B = 1.963, SE = 0.892, β = 0.151, t = 2.202, p = .029), suggesting that individuals with higher education levels experienced higher psycholog- ical distress. The results of this analysis revealed that after controlling for these covariates, the relationship between BRS and IGT-AD scores remained statistical- ly significant (F(22,153) = 1.877, p = .015, η² = .212)). Mediator Analysis The mediator analysis results are reported in Ta- ble 3. The analysis of family history revealed a non-sig- nificant effect on IGT-AD scores (p = .163), suggest- ing family history did not significantly influence the scores. The interaction term between BRS scores and family history did not significantly contribute to the variance in IGT-AD scores (R² = 0.011, F(1, 175) = 2.326, p = 0.129), suggesting that the relationship between BRS scores and IGT-AD scores were not influenced by the presence of family history. Boot- strap analysis further supported the regression results. Discussion The present study investigated the relationship between resilience and psychological distress resulting from genetic testing for Alzheimer's disease among unimpaired individuals. The findings indicated a sig- nificant negative correlation between resilience and psychological distress, indicating that higher levels of resilience were associated with lower levels of distress related to genetic testing for Alzheimer's disease, ir- respective of age and gender. These results support previous research that resilience can act as a protective factor against psychological distress in the context of genetic testing for hereditary diseases (Ho et al., 2010). The negative correlation between resilience and psychological distress suggests that individuals with higher resilience may cope more effectively with the po- tential implications of genetic testing for Alzheimer's disease. Resilience allows individuals to adapt positive- ly to challenging situations and adversities (Garmezy, 1991), which may translate into reduced distress when faced with the possibility of developing Alzheimer's disease. Higher levels of resilience may enable individ- uals to maintain emotional well-being despite the per- ceived threat of the disease and the uncertainty associ- ated with genetic testing results (Yasien et al., 2016). 10 BURGEI The results also showed that family history did not significantly mediate the relationship between resil- ience and psychological distress. This suggests that in- dividuals with higher resilience may be better equipped to cope with the emotional impact of genetic testing, re- gardless of their family history. While a family history of Alzheimer's disease can increase the risk of developing the condition (Liu & Cao, 2014), it did not significant- ly impact how resilience influenced the psychological distress associated with genetic testing for the disease. The development and use of the IGT-AD scale were essential in measuring the psychological im- pact of genetic susceptibility to Alzheimer's disease (Chung et al., 2009). Previous scales primarily tar- geted depression and anxiety, but the IGT-AD scale provides a more specific and sensitive measure for assessing distress specifically related to Alzheimer's disease genetic testing. Using validated and reli- able measures, such as the IGT-AD and the BRS, strengthens the study's validity and supports the generalizability of the findings to other populations undergoing genetic testing for hereditary diseases. The present study contributes to the existing lit- erature by focusing on unimpaired individuals' psy- chological distress related to genetic testing for Alzhei- mer's disease. Understanding the factors that influence individuals' responses to genetic testing is crucial, as it can help identify those at higher risk of experiencing distress and guide the development of tailored inter- ventions. The results suggest that resilience-based interventions may be beneficial for individuals un- dergoing genetic testing for Alzheimer's disease, as they may help mitigate the psychological distress asso- ciated with receiving test results (Wang et al., 2021). Limitations The present study had some limitations that should be acknowledged. The sample consisted of a convenience sample of unimpaired individuals recruit- ed online, limiting the generalizability of the findings to the broader population. Future research could aim to recruit a more diverse and representative sample to increase external validity. The study's cross-section- al design does not allow for causal inferences, and future longitudinal studies can better examine the relationship between resilience and psychological dis- tress over time. It is crucial to acknowledge that the IGT-AD and BRS scales were not counterbalanced in this study, thereby introducing the possibility of order effects influencing participants' responses. Self-report measures are subject to response biases, and participants may have provided socially desirable responses, leading to potential measurement errors. Another potential limitation arises from the re- liance on participant-reported family history of Alz- heimer's disease. This information could be subject to variations in accuracy, as it depends on participants' knowledge and the extent of their inquiries within their families. Some participants may have inquired about Alzheimer's disease in only a few generations, while others may have gone further back in their fam- ily tree. For future research, adopting more standard- ized and comprehensive methods for assessing family history may enhance the accuracy of this variable. Implications and Future Research The study's findings have several implications for clinical practice and future research. First, identifying individuals at higher risk of psychological distress re- lated to genetic testing can inform the development of targeted support and counseling services to help individuals cope with the emotional impact of test results. Healthcare providers should consider incorpo- rating resilience-based interventions as part of pre-and post-genetic counseling for Alzheimer's disease and other hereditary conditions. Such interventions may help individuals develop coping strategies and enhance their emotional well-being in the face of potential risk ultimately aiding in the reduction of stress that can contribute to the accelerated progression and neuro- degeneration of Alzheimer's disease (Justice, 2018). While the present study did not explicitly assess the temporal aspect of psychological distress, it is es- sential to acknowledge that distress may vary over time. Genetic testing results can trigger acute stress reactions, followed by an adjustment period. For some individuals, this psychological distress may be tempo- rary, while for others, it may extend into a more pro- longed and chronic experience. Future research could delve into the dynamics of psychological distress over time in relation to genetic testing results, examin- ing the factors influencing its duration and intensity. Future research should explore other potentially protective factors, such as social support, coping strat- egies, and personality traits, to gain a comprehensive understanding of the factors that influence psycholog- ical distress related to genetic testing for Alzheimer's disease. Longitudinal studies can also provide insights 11 RESILIENCE AND PSYCHOLOGICAL DISTRESS into how resilience evolves over time in response to receiving genetic testing results and the progression of Alzheimer's disease. Additionally, examining the long-term impact of genetic testing results on psy- chological well-being and behavior, especially in those with a family history of Alzheimer's disease, can offer valuable information for personalized interventions. Conclusion In conclusion, the present study adds to the grow- ing body of literature on psychological distress related to genetic testing for Alzheimer's disease by examining the role of resilience as a protective factor. The findings highlight the importance of resilience in coping with the potential emotional impact of receiving genetic testing results and suggest that resilience-based inter- ventions may be beneficial in supporting individuals undergoing genetic testing for Alzheimer's disease. 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Saudi Medical Jour- nal, 37(7), 778-782. https://doi.org/10.15537/ smj.2016.7.15004 BURGEI 13 RESILIENCE AND PSYCHOLOGICAL DISTRESS Table 1 Sociodemographic Characteristics of the Participants 14 BURGEI Table 2 Survey Descriptive Statistics 15 RESILIENCE AND PSYCHOLOGICAL DISTRESS Table 3 Mediator Analysis 16 BURGEI Figure 1 Scatterplot of BRS and IGT-AD Total Scores 17 RESILIENCE AND PSYCHOLOGICAL DISTRESS Figure 2 Normality Distribution of IGT-AD and BRS Total Scores 18 BURGEI Appendix 1 The Reveal Impact of Genetic Testing in Alzheimer’s Disease Scale (IGT-AD) The questions below are about specific responses you may have about receiving your Alzhei- mer’s disease genetic test results. Please evaluate your response to receiving your results and answer every question in this section. Indicate whether you strongly disagree, disagree, agree, or strongly agree with each statement, by selecting the corresponding response. 19 RESILIENCE AND PSYCHOLOGICAL DISTRESS Note. Items 4, 5, 14, and 15 are reverse scored. To score, add the responses varying from 1-5 for all sixteen items, giving a range from 0-80. 20 BURGEI Appendix 2 Brief Resilience Scale (BRS) Note. Items 2, 4, and 6 are reverse scored. To score, add the responses varying from 1-5 for all six items, giving a range from 6-30. 21 RESILIENCE AND PSYCHOLOGICAL DISTRESS Questionnaire 1 Family History and Demographic Questions