Development and Application of the Trauma Symptom Inventory™-2 (TSI™-2) Trauma Symptom Inventory-2 (TSI™-2) The Trauma Symptom Inventory-2 (TSI-2) is a revised version of the Trauma Symptom Inventory (TSI™; Briere, 1995), a widely used test of trauma-related symptoms and behaviors. This measure evaluates acute and chronic symptomatology, including, but not limited to, the effects of: • Sexual and physical assault • Intimate partner violence • Combat • Torture • Motor vehicle accidents • Mass casualty events • Medical trauma • Witnessing violence or other trauma • Traumatic losses • Early experiences of child abuse or neglect It evaluates symptomatology associated with trauma at any point in the respondent’s lifespan; it does not link symptoms to a single stressor or specific point in time. Trauma Symptom Inventory-2 (TSI-2) • 136 items • Assesses a wide range of potentially complex symptomatology. (i.e., posttraumatic stress, dissociation, somatization, and dysfunctional behaviors. • Normed and standardized on a representative sample of the United States general population. • It consists of 2 validity scales, 12 clinical scales, 12 subscales, and 4 factors Goals for the Revision • To update existing items and skills to reflect new developments and research in the field of trauma • To respond to feedback from clinicians and researchers regarding strengths and limitations of the TSI • To provide additional scales in order to measure symptom clusters not included in the TSI • To address concerns regarding utility of the original ATR scale in detecting malingering of PTSD in forensic settings • To modify the AA scale to include hyperarousal • To provide continuity between the TSI and the TSI-2 TSI to TSI-2 • Added three (3) scales - Insecure Attachment (IA); Somatic Preoccupations (SOM); and Suicidality (SUI). • Added two (2) subscales - Anxious Arousal–Hyperarousal (AA-H) and Impaired Self-Reference–Other-Directedness (ISR-OD). • The four TSI™-2 factors (Self-Disturbance (SELF); Posttraumatic Stress (TRAUMA); Externalization (EXT); and Somatization (SOMA) are either new to this version (EXT) and (SOMA) or reconfigured based on newly added or modified scales (SELF) and (TRAUMA). • The TSI™-2 validity scales contain new items, especially the Atypical Response (ATR) scale, which was redesigned to assess not only overreporting in general, but also to better evaluate potential misrepresentation of posttraumatic stress disorder (PTSD). In all, 87 items (i.e., 64%) are new to the TSI-2 or have been rewritten to some degree. • Added a Reliable Change Score • No racial differences were found on the ATR scale in the TSI-2. For this reason, the TSI™-2 does not require any adjustment of ATR scores for any specific racial or ethnic group. Why the TSI-2? • In the general population, the lifetime prevalence of PTSD is approximately 8%. • Prevalence rates in combat veterans, torture survivors, rape victims, refugees, and other individuals exposed to extremely stressful events can have rates as high as 30 to 60% (Breslau, Davis, Andreski, & Peterson, 1991; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Marshall, Schell, Elliott, Berthold, & Chun, 2005; Ramchand et al., 2010; Steel et al., 2009). Copyright © 2012 by David M. Schwartz, Ph.D. All rights reserved. Why the TSI-2? There is a wide variety of non-PTSD-specific symptoms that are associated with childhood and adult interpersonal victimization. These include: • • • • • • • • • • Mood disturbances such as anxiety, depression, or anger (e.g., Gilboa-Schechtman & Foa, 2001; Heim & Nemeroff, 2001) Somatization (e.g., Dietrich, 2003; Walker, Katon, Roy-Byrne, Jemelka, & Russo, 1993) Identity disturbance (e.g., Briere & Rickards, 2007; Cole & Putnam, 1992) Difficulties in emotional regulation (e.g., van der Kolk et al., 1996; Zlotnick, Donaldson, Spirito, & Pearlstein, 1997) Insecure attachment styles (e.g., Cloitre, Stovall-McClough, Zorbas, & Charuvastra, 2008; Harari, Bakermans-ranenburg, & Van IJzendoorn, 2007) Chronic interpersonal difficulties (e.g., Elliott, 1994; Pietrzak, Goldstein, Malley, Johnson, & Southwick, 2009) Dissociation (e.g., Briere, Scott, & Weathers, 2005; Chu, Frey, Ganzel, & Matthews, 1999) Substance abuse (e.g., Ouimette & Brown, 2003; Najavits, 2002) Suicidal thoughts and behaviors (Bebbington et al., 2009; Panagioti, Gooding, & Tarrier, 2009) Tension reduction or externalization activities such as compulsive sexual behavior, bulimic eating, impulsive aggression, and self-mutilation (e.g., Briere & Gil, 1998; Zlotnick et al., 1997). These are not mutually exclusive! Why the TSI-2? • Sometimes, symptoms are diverse and appear to arise from multiple adverse events, leading some clinicians refer to complex posttraumatic outcomes, disorders of extreme stress, or complex PTSD. • Sometimes, symptoms include affect dysregulation, externalizing behaviors and relational disturbances. These may be organized as DSMIV-TR Cluster B diagnoses. • Given the range of potential outcomes, administration of a measure that is limited to PTSD or some other single symptom or syndrome is unlikely to be sufficient to form an accurate or comprehensive clinical view of the trauma survivor (Courtois, 2004). • Many potential moderators and mediators of posttraumatic outcomes, including degree or frequency of trauma exposure, preexisting affect regulation capacity, relational context, and comorbid psychological symptoms or disorders may make it difficult to conclude that Trauma X is associated with Outcome Y without also taking such factors into consideration. TSI-2-A • The alternate 126-item version of the form does not contain any sexual symptom items—the Sexual Disturbance scale (i.e., the Sexual Concerns and Dysfunctional Sexual Behavior subscales) and the sexual symptom items associated with the Externalization factor have been removed. • Eight critical items help you identify issues or behaviors that potentially represent severe psychological disturbance, danger to the respondent, or danger to others. • Reliable change scores are new to this edition of the measure and allow you to track progress and monitor change over time. • The validation sample consisted of five non-overlapping clinical groups: combat veterans, individuals with borderline personality disorder, sexual abuse victims, victims of domestic violence, and incarcerated women. A sample of subjects simulating PTSD was used to test malingering. Appropriate Populations • The TSI-2 was designed as a broad-spectrum assessment of trauma-related symptoms and behaviors. • It can be used to evaluate adults in a variety of clinical settings including hospitals, inpatient and outpatient clinics, and schools. • It is appropriate for use with multiple presenting problems including posttraumatic stress, insecure attachment, impaired selfreference, somatization, and “acting out” behaviors. • The TSI-2 was standardized and validated on men and women in the general population, ages 18 years and older. Separate normative data are available for different genders and ages. • Flesch-Kincaid readability analyses indicate that a fifth-grade reading level is required to complete the TSI-2.