MILITARY MEDICINE ORIGINAL ARTICLES

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1 VOLUME 174 OCTOBER 29 NUMBER 1 MILITARY MEDICINE ORIGINAL ARTICLES Authors alone are responsible for opinions expressed in the contribution and for its clearance through their federal health agency, if required. MILITARY MEDICINE, 174, 1:15, 29 Utility of the Trauma Symptom Inventory for the Assessment of ost-traumatic Stress Symptoms in Veterans With a History of sychological Trauma and/or Brain Injury Nazanin H. Bahraini, hd*; Lisa A. Brenner, hd*tt ; Jeri E. F. Harwood, hdh; Beeta Y. Homaifar, hd*t; Susan E. Ladley-O'Brien, MDf, Christopher M. Filley, MDf ; James. Kelly, MDtH; Lawrence E. Adler, MD*t ABSTRACT Correspondence of three core Trauma Symptom Inventory (TSl) posttraumatic stress disorder (TSD) scales (Intrusive Experiences, Defensive Avoidance, and Anxious Arousal) and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV) TSD module were examined among 72 veterans with traumatic brain injury (TBI), TSD, or both conditions. Subjects were classified into TSD only, TBI only, or co-occurring TSD and TBl groups based on TBI assessment and SCID-IV TSD diagnosis. Linear regression was used to model TSl T-Scores as a function of group. Scores on all three scales significantly differed between the TBI and TSD groups (TSD only and co-occurring TSD and TBI) in the expected direction. Study findings indicate that despite the potential overlap of symptoms between TSD and TBI, the TSl appears to be a useful measure of trauma-related symptoms in veterans who may also have a TBI, particularly mild TBI. Limitations and areas for future research are discussed. INTRODUCTION Metital health professionals working with military personnel and veterans are often faced with the task of assessing and diagnosing post-traumatic stress disorder (TSD). This can be particularly challenging when individuals present with comorbid medical conditions, such as traumatic brain injury (TBI), in which varying degrees of cognitive and emotional sequelae are often observed. Sumpter and McMillan' suggest that TBI sequelae, such as memory deficits resulting from loss of consciousness and post-traumatic amnesia, decreased participation, social withdrawal, and adjustment problems postinjury *VA VISN 19 Mental Illness Research, Education and Clinical Center (MIRECC), 155 Clermont Street, Denver, CO 822. t Department of sychiatry, University of Colorado School of Medicine, 131 East 17th lace, Aurora, CO 845. t Department of hysical Medicine and Rehabilitation, University of Colorado School of Medicine, 131 East 17th lace, Aurora, CO Department of Neurology, University of Colorado School of Medicine, 131 East 17th lace, Aurora, CO 845. II Department of ediatrics, University of Colorado School of Medicine, 131 East 17th lace, Aurora, CO Department of Neurosurgery, University of Colorado School of Medicine, 131 East 17th lace, Aurora, CO 845. This manuscript was received for review in March 29. The revised manuscript was accepted for publication in June 29. may be confused with TSD symptoms. Moreover, symptom overlap between TBI and TSD, including insomnia, irritability, and impaired concentration can further contribute to difficulty distinguishing between these two conditions.'"' Despite these challenges, accurate assessment and diagnosis of TSD in the veteran population is needed to inform treatment and determine service-connected disability. As such, best practice guidelines established by the Department of Veterans Affairs suggest that clinicians use multiple sources of information, including clinical interview, psychometric testing, and review of military and medical records to ensure accurate assessment of TSD."* The use of psychometric measures, in particular, has been strongly recommended to supplement interview methods when assessing TSD symptoms in veterans who present with multiple and confusing comorbid disorders.** Among the specific psychometric measures recommended for use by VA clinicians in the assessment of TSD is the Trauma Symptom Inventory (TSI)."-' The TSl is a 1-item self-report measure that was created to assess TSD symptoms and a variety of other related sequelae. The TSl is cotnposed of 3 validity scales and 1 clinical scales, 3 of which are closely related to the symptom clusters presented in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for TSD.* These scales include MILITARY MEDICINE, Vol. 174, October 29 15

2 Trauma Symptom Inventory for the Assessment of ost-traumatic Stress Symptoms intrusive experiences (IE), defensive avoidance (DA), and anxious arousal (AA),^ and respectively correspond to the cluster B (re-experiencing), cluster C (avoidance), and cluster D (hyperarousal) TSD symptoms listed in the DSM-IV.* Although a number of studies have shown good convergence between the TSI and other well-established measures of TSD, few studies have examined its use with veterans, and no studies to date have examined whether the TSI is an effective tool in the assessment of TSD in veterans with co-occurring TSD and TBI. This is a particularly important topic as some have cautioned against the use of self-report measures to assess TSD in those with a history of TBI, particularly severe TBI, indicating that such questionnaires may produce errors whereby symptoms that are caused by brain injury are mistakenly attributed to TSD.' Given the increased likelihood of both TB"' and exposure to psychological trauma among military service members compared to the general population,' " it is important to establish that measures such as the TSI enhance diagnostic accuracy. The purpose of this study was to examine the correspondence of the three TSI core TSD scales and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV)'^ TSD module in a sample of veterans with TSD, TBI, or both conditions. Specifically, differences in scores on these three scales between those who were and were not diagnosed with TSD using the SCID-IV were examined. It was hypothesized that scores on the three TSI clinical scales related to the core symptoms of TSD (IE, DA, and AA) would be significantly higher for individuals with TSD only and those with TSD and TBI compared to those with a TBI only. METHODS Subjects and rocedures This is a secondary analysis of data gathered during an observational study, which was conducted to assess veterans with TBI and/or TSD.'' Subjects consisted of 72 veterans with TBI and/ or TSD receiving care within a Veterans Affairs (VA) Health Care System serving individuals from both rural and urban areas. Veterans receiving outpatient and inpatient services for TBI and/or TSD were eligible for participation. These 72 individuals originally completed a battery of neuropsychological and psychological measures including the TSI, the SCID-IV, and the Beck Depression Inventory-II (BDI-II).''* Inclusion and exclusion criteria, as well as procedures and demographics for the original sample of 72, are listed elsewhere.'^ Eor this secondary analysis, subjects were classified into one of the following three groups: TSD, TBI, or co-occurring TSD and TBI, based on TBI assessment and SCID-IV TSD diagnosis. Scores on selected TSI scales reñecting core TSD symptoms were then compared across these three groups. Measurement Traumatic Brain Injury In the original study, presence or absence of participant TBI history was determined by a clinical psychologist or a physiatrist using information obtained via interview and chart review. Criteria set forth by the Centers for Disease Control'' were utilized. Injury severity was determined by a physiatrist on the basis of criteria outlined by the Department of Veterans Affairs.'* Specifically, injury severity was classified as mild, moderate, or severe according to initial Glasgow Coma Score, duration of coma, loss of consciousness, historical imaging results, and/or length of post-traumatic amnesia. articipant TBI classification was determined on the basis of the subject's lifetime history of most significant injury. ost-traumatic Stress Disorder Subjects in the original study were administered the SCID-IV '^ The SCID-IV is a semistructured interview used to make DSM-IV Axis I diagnoses, which has been shown to have greater diagnostic accuracy when compared to the unstandardized methods of eliciting diagnostic criteria most often used by clinicians.'^ All interviews were conducted by individuals trained in the use of the SCID-IV, and oversight was provided by a rehabilitation psychologist. Good inter-rater reliability (.87 current,.94 lifetime), sensitivity (.81), and specificity (.98) have been reported for the SCID-IV when used by trained clinicians to assess TSD in a veteran population.'" In this study, the SCID-IV TSD module was used to assess veterans' TSD symptoms at the time of the interview. Veterans were assigned a diagnosis of TSD if they reported exposure to a traumatic event and obtained a score of 3 on each of the following: both criteria A1 and A2, at least 1 cluster B symptom, 3 cluster C symptoms, and 2 cluster D symptoms. The TS as described above, was also administered as part of the original assessment battery to assess TSD symptoms, but was not used in the initial analyses. The TSI has demonstrated good internal consistency in samples of university students (.84), psychiatric inpatients and outpatients (.87), and Navy recruits (.85). Evidence for various indicators of construct validity for the TSI clinical scales has also been demonstrated.'^"^' In this study, scores on 3 of the 1 TSI clinical scales (IE, DA, and AA) corresponding to TSD symptoms listed in the DSM-IV served as the primary dependent variables. revious research^ has shown convergence between these three scales of the TSI and two other widely used self-report measures of post-traumatic stress, namely the Impact of Events Scale (IES) and the Symptom Checklist (SCL). Specifically, analyses using a subset of the standardization sample revealed that AA correlated highest with the SCL Arousal subscale; IE had the highest correlation with the Intrusion subscales of the SCL and IES; and DA showed the strongest correlation with the IES and SCL Avoidance subscales.' Because it contained two items consistent with emotional numbing and was identified as one of the scales reñecting post-traumatic stress in the TSI professional manual,' the dissociation (DIS) was also included in the analysis. Scores on the three TSI validity scales were examined, and a subgroup analysis excluding invalid profiles was also conducted. rofiles were considered invalid if subjects exceeded recommended cut-off scores listed in the TSI manual on any of the three validity scales. Specifically, these included any of the following: an atypical 16 MILITARY MEDICINE, Vol. 174, October 29

3 Trauma Symptom inventory for the Assessment of ost-traumatic Stress Symptoms response (ATR) T-score > 9, a response level (RL) T-score > 73, or an inconsistent response (INC) 7-score > 75.' Depression and Substance Abuse Depressive symptoms and a history of lifetime problematic alcohol and drug use, which were assessed in the original study, were examined for confounding effects. The BDI-II'"* was used to measure severity of depressive symptoms. In the original study, individuals were excluded if they obtained BDI-II scores that were more than two standard deviations higher than a historical mean of scores obtained by individuals participating in the medical center's TSD Residential Rehabilitation rogram. History of lifetime problematic alcohol use was defined as a SCID-IV identified alcohol use disorder, an average consumption of more than six drinks per day, or subject endorsement of alcohol use causing significant problems in functioning.'^ Any nonexperimental use of illicit drugs excluding marijuana was coded as a history of lifetime problematic drug use. overall type I error rate. A subgroup analysis was run excluding the invalid TSI profiles, controlling for BDI-II scores. RESULTS Subject Characteristics See Table I for subject characteristics. On the basis of SCID-IV TSD module and TBI assessment results, subjects were classified into one of the following three groups: TSD (A' - 13), TBI (A' = 27), or co-occurring TSD and TBI (A^ = 32). TBI severity is presented in Table II.'' Scores on at least one TSI validity scale exceeded cut-off scores for 16 subjects resulting in invalid profiles for these individuals (Table III). Invalid scores on more than one validity scale were not observed for any of the subjects. Group means and standard deviations of TSI T-Scores for all profiles and with invalid profiles removed are depicted in Table IV. The estimated group differences for each of the TSI scales that are reported in Table V control for BDI-II scores. Data Analysis All analyses were run in SAS v9.1 (SAS Institute, Inc., Cary NC) and assumed a two-sided test of hypothesis with an overall significance level of.5 unless otherwise noted. Demographic characteristics across the three groups were compared using Fisher's exact tests for categorical variables and a Kruskal-Wallis test for continuous variables. Data are reported as means and standard deviations (SD), medians and ranges, and percentages, as appropriate. Linear regression was used to model all TSI T-scores (four regressions) as a function of group (TBI, TSD, and co-occurring TSD and TBI). Subject characteristics compared across groups with a resulting/7 value <.2 were investigated for confounding effects. Each qualifying characteristic variable was assessed individually and only those variables with a substantial attenuating effect on group estimates were retained. For all outcomes, only BDI-n scores were found to substantially attenuate the estimated group means. airwise group comparisons were made while employing a Bonferroni adjustment to control the TABLE I. TSI Scales Intrusive Experiences The overall group test was significant F (2, 68) = 15.14, p <.1. ost-hoc analyses using a Bonferroni adjustment revealed that the estimated mean IE score was significantly lower in the TBI group than in the TSD group {p <.1 ), and in the co-occurring (TSD and TBI) group (p =.1). That is, individuals in the TBI group scored an average of 18 points (95% CI, points) less than the TSD group and an average of 13.6 points (95% CI, points) less than the co-occurring TSD and TBI group on a scale measuring intrusive experiences. Comparable results were seen when the invalid profiles were removed. Defensive Avoidance Similarly, results showed a group effect on measures of defensive avoidance, F (2, 68) = 12.18, /? <.1. ost-hoc analyses using a Bonferroni adjustment revealed that the estimated mean DA score was also significantly lower in the TBI group articipant Characteristics Characteristic Age Mean (SD) Median (Range) Alcohol Use N (%) Yes No Drug Use N (%) Yes No BDI Score Mean (SD) Median (Range) Education N (%) <High School High School >High School All N=12 52 (9.7) 55.5 (23-74) 51(71) 21 (29) 23 (32) 49 (68) 26.8(14.2) 28 (-53) 2(3) 19(26) 51(71) TSD Only A'= (5.3) 56(43-6) 1(77) 3(23) 3(23) 1(77) 28.3(12.) 28 (4-^5) 1(8) 12(92) TBI Only ^ = (11.1) 5 (23-74) 14(52) 13(48) 7(26) 2 (74) 18.1 (14.2) 14(-48) 9(33) 18(67) TSD lus TBI Af= (9.6) 57(32-64) 27 (84) 5(16) 12(37.5) 2 (62.5) 33.6(11.) 34.5(11-53) 2(67) 9(28) 21 (66) Value =.\ 8" =.3' ^ =.56' =.5" =.24* "Kruskal-Wallis. 'Fisher's Exact. MILITARY MEDICINE, Vol. 174, October 29 17

4 Trauma Symptom Inventory for the Assessment of ost-traumatic Stress Symptoms Diagnosis TABLE II. N TSD Only 13(18.1%) TBI Only 27 (37.5%) Both (TBI lus TSD) 32 (44.4%) Validity Scale Atypical Response (ATR) Response Level (RL) Inconsistent Response (INC) TABLE IV. TBI and TSD Diagnosis Mild TBI 3(11.1%) 24 (88.9%) Moderate TBI 7 (63.6%) 4 (36.4%) TABLE II 1. Invalid rofiles All rofiles N 13(81%) (%) 3(19%) TSD Only 5 (83.3%) (%) 1 (16.7%) Severe TBI 17(81.%) Mean (SD) of TSI r-scores by Group 4(19.%) TSD and Mild TBI 8 (8%) (%) 2 (2%) Without Invalid rofiles" TSI TSD Only TBI Only Both» TSD Only Both» Scale («=13) (n = 27) (n = 32) (n = 7) («= 22) IE 78.9(13.8) 55.4(9.9) 77.4(13.2) 74.9(16.4) 73.5(12.6) DA 73.7(1.1) 55.5(9.9) 71.2(9.8) 73.(1.5) 68.8(9.8) AA 75.9(1.5) 52.7(8.4) 73.6(13.4) 74.(12.4) 69.3(13.2) "There were no invalid profiles in the TBI only group. ''Both, co-occurring TSD and TBI. TABLE V. Groups' -T -B B-T Groups» -T -B B-T Groups» -T -B B-T Estimated Differences Between Least Squares Means Adjusted for BDI-II Score with 95% CIs" IE All rofiles 18.(9.2,26.8) 4.4 (-3.9, 12.7) 13.6(6.,21.1) DA 13.7(6.6,2.9) 4.8 (-2., 11.6) 9.(2.8, 15.1) AA 18.6(1.2,27.) 4.8 (-3.2, 12.7) 13.8(6.6,21.) <O.OOOI.59.1 < <O.OOOI.44 <.1 Without Invalid rofiles IE 15.(4.3,25.7) 3.1 (-7.7, 13.8) 11.9(4.2, 19.7) DA 13.7(4.8,22.6) 5.7 (-3.2, 14.6) 8.(1.5,14.5) AA 17.8(7.3,28.3) 6.1 (-4.4, 16.6) 11.7(4., 19.3) "All CIs and p-values are adjusted using a Bonferroni correction.», TSD only («= 13 for all profiles and «= 7 without invalids). T, TBI only (n = 27 for both estimates). B, co-occurring TSD and TBI («= 32 for all profiles and n = 22 without invalids). than in the TSD group (p <.1), and in the co-occurring (TSD and TBI) group {p =.2). Individuals in the TBI group scored an average of 13.7 points (95% CI, points) less than the TSD group, and an average of 9. points (95% CI, points) less than the co-occurring TSD and TBI group on the DA scale. Again, comparable results were seen when the invalid profiles were removed. Anxious Avoidance The overall group test was also significant for scores on the Anxious Arousal scale, F (2, 68) = 17.5, p <.1. osthoc analyses using a Bonferroni adjustment revealed that the estimated mean AA score was significantly lower in the TBI group than in the TSD group {p <.1), and in the cooccurring (TSD and TBI) group {p <.1). Individuals in the TBI group scored an average of 18.6 points (95% CI, points) less than the TSD group and an average of 13.8 points (95% CI, points) less than the cooccurring TSD and TBI group on symptoms of anxious arousal. Removal of invalid profiles produced similar results. Dissociation The overall group test was significant for scores on the Dissociation scale f (2,68) = 9.81, p =.2. ost-hoc analyses using a Bonferroni adjustment revealed that the estimated mean DIS score in the TSD group was significantly higher than the mean in the TBI group {p =.1), and in the co-occurring group {p -.2). When the invalid profiles were removed from the analysis, the significant difference between the estimated mean DIS for the TSD group and the TBI group was maintained (p -.2), but there was no longer a significant difference between the TSD group and the co-occurring group {p =.27). DISCUSSION Overall, the findings of this study suggest that the three TSD-focused TSI scales demonstrated good correspondence with the SCID-IV TSD module, a well-accepted measure of TSD, in this sample of veterans. When controlling for depressive symptoms, scores on all three core TSD clinical scales of the TSI (IE, DA, and AA) differed between the TBI and the two TSD groups (TSD and co-occurring TSD and TBI). As expected, mean T-scores for the two TSD groups were significantly higher than those for the TBI only group across the three primary outcome measures (IE, DA, and AA). Moreover, despite the potential overlap of symptoms between TBI and TSD,'-^ the presence of TSD either alone or in conjunction with TBI, was associated with clinically significant T-scores on the three core TSD scales examined, while the mean T-scores of those in the TBI group were in the subclinical range on these three scales. The absence of significant differences on the IE, DA, and AA scales between individuals with TSD and those with co-occurring TSD and TBI provides support for the TSI in the assessment of TSD symptoms in individuals who may present with both conditions. One limitation of this study was the uneven distribution of TBI severity for those in the co-occurring group. The majority of individuals in this group (n = 24) had a mild TBI, whereas the majority of individuals in the TBI group (n- 17) were identified as having a severe TBI. Given the make-up of this sample, these findings lend support for the TSI in the assessment of TSD symptoms in veterans with co-occurring TSD and mild TBI. However, additional research with a more balanced range of TBI severity is encouraged to examine whether these findings are generalizable to circumstances in which TSD occurs in the context of a moderate or severe TBI. Along these lines, the exclusion of individuals with extremely elevated BDI-Il scores in the original study may also impact the generalizability 18 MILITARY MEDICINE, Vol. 174, October 29

5 Trauma Symptom Inventory for the Assessment of ost-traumatic Stress Symptoms of these findings as such severe levels of depression may impact how symptoms of TSD are experienced and hence reported. Another notable finding was that the removal of invalid profiles did not impact group differences for the core TSD scales. In addition, all of the invalid profiles in this sample of veterans solely occurred among individuals in the TSD or co-occurring TSD and TBI groups. Because invalid profiles on the TSI may be attributable to a number of different factors, including overendorsement of symptoms, random responding or marked degrees of psychological distress, the fact that no invalids were observed in the TBI group has important implications. While previous research suggests that the use of self-report measures to assess TSD symptoms in those with severe brain injury can lead to errors and overdiagnosis of TSD in this population,' the findings from the current study revealed a very different picture. That is, individuals in the TBI group, regardless of severity level, were not only able to complete the questionnaire and produce valid profiles, but did not overendorse symptoms when compared to those who did, in fact, have a diagnosis of TSD. Also worth noting is the lack of difference between the TBI and co-occurring TSD and TBI groups on the DIS scale. In general, the TBI group endorsed more symptoms on the DIS scale compared to the three core TSD scales, which may be the result of similarities between dissociative symptoms and certain TBIrelated cognitive and sensory sequelae. erhaps, more importantly, this finding suggests that emphasis should be placed on scales that assess core TSD symptoms when using the TSI to enhance diagnostic accuracy in those with co-occurring conditions. Because the TSI is one of the measures recommended by the Department of Veterans Affairs in the assessment of TSD in military veterans, studies supporting its use with this population are crucial, particularly in light of the current conflicts in Iraq and Afghanistan. Although the current study's sample included a small number of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) veterans, the prevailing conditions in this sample, namely, TSD and/or TBI, suggest that the TSI may be a potentially useful measure of TSD with this cohort of veterans. Circumstances unique to this war, such as the prominence of improvised explosive devices (IEDs), high rates of blast exposures, extended tours of duty, and civil unrest compounded with more general Stressors associated with combat, place soldiers at increased risk for both TBI and TSD. In fact, not only has TBI been identified as a signature wound of these conflicts, but there is also evidence indicating that TSD symptoms are more common in those with TBI." As such, it is important that measures of TSD that are being used with veterans, such as the TSI, help promote diagnostic accuracy, particularly when applied in clinically complicated situations. Findings from this study indicate that despite the potential overlap of symptoms between TSD and TBI,'-' the TSI appears to be a useful measure of symptoms of psychological trauma in veterans who may also have a TBI, particularly mild TBI. Furthermore, the TSI offers a number of advantages over other self-report measures, including scales that measure response validity, core TSD symptoms, and broader symptoms related to trauma (e.g., tension-reducing behaviors. depression, and dissociation), all of which enhance the TSI's clinical utility, enabling clinicians to take into consideration a number of different factors when identifying the most effective course of treatment for their veteran patients. ACKNOWLEDGMENTS Funding for this project was provided by the Colorado Traumatic Brain Injury Trust Fund Research rogram and the VA VISN 19 MIRECC. REFERENCES 1. Sumpter RE, McMillan TM; Errors in self-report of post-traumatic stress disorder after severe traumatic brain injury. 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