Financial Burden of Dental Care Among Patients With Head and Neck Cancer.

Importance: Patients undergoing treatment for head and neck cancer (HNC) experience oral complications requiring substantial dental treatment. This treatment is commonly not reimbursed by medical insurers, presenting a potential financial burden for patients. Objective: To characterize the dental care needs and associated cost burden for patients with HNC. Design, Setting, and Participants: This survey study included Head and Neck Cancer Alliance (HNCA) members who were surveyed from March 23 to October 27, 2023, using Qualtrics. The survey was promoted using the HNCA's social media and email list. Data analysis was performed between October 2023 and May 2024. Main Outcomes and Measures: Main outcomes were oral and dental complications of cancer treatment among patients with HNC, the association of cancer treatment with dental care use, and costs of associated dental treatment. Results: Of 100 individuals administered the survey, 85 (85%) completed all required questions and were included in the analysis. Of 84 participants with age and sex data, 51 (61%) were aged 65 years or older and 45 (54%) were female. Of 85 respondents, 59 (70%) indicated that their current oral health was worse than before cancer treatment. Most respondents (73 of 85 [86%]) endorsed oral complications from cancer treatment, including xerostomia (66 of 73 [90%]), caries (35 of 73 [48%]), and oral mucositis (29 of 73 [40%]); 64 of 73 respondents (88%) required follow-up dental treatment. Overall, 4 of 28 (14%) before HNC treatment and 17 of 53 (32%) after treatment reported finances as the reason that not all recommended dental care was received. A total of 33 of the 85 respondents (39%) said that their postcancer dental care had caused them financial hardship. Individuals who were less likely to endorse financial hardship were more likely to have greater educational attainment (odds ratio [OR], 0.20; 95% CI, 0.06-0.58), higher income (OR, 0.33; 95% CI, 0.11-0.94), increased pre-HNC dental visit frequency (OR, 0.30; 95% CI, 0.10-0.86), same or better oral health after HNC (OR, 0.13; 95% CI, 0.02-0.50), and lower out-of-pocket dental expenses after HNC (OR, 0.09; 95% CI, 0.03-0.29). Conclusions and Relevance: In this survey study, most patients undergoing treatment for HNC required extensive dental treatment throughout cancer treatment; this treatment presented a financial burden for 39% of patients that was a limiting barrier to care. Since most private medical insurers do not reimburse for dental treatment, more comprehensive coverage deserves policy attention.

Clusters Based on Within-Treatment Symptom Trajectories as Predictors of Dropout in Treatment for Posttraumatic Stress Disorder and Substance Use Disorder.

Objective: Dropout rates are high in treatments for co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUDs). We examined dropout predictors in PTSD-SUD treatment. Methods: Participants were 183 veterans receiving integrated or phased motivational enhancement therapy and prolonged exposure. Using survival models, we examined demographics and symptom trajectories as dropout predictors. Using latent trajectory analysis, we incorporated clusters based on symptom trajectories to improve dropout prediction. Results: Hispanic ethnicity (integrated arm), Black or African American race (phased arm), and younger age (phased arm) predicted dropout. Clusters based on PTSD and substance use trajectories improved dropout prediction. In integrated treatment, participants with consistently-high use and low-and-improving use had the highest dropout. In phased treatment, participants with the highest and lowest PTSD symptoms had lower dropout; participants with the lowest substance use had higher dropout. Conclusions: Identifying within-treatment symptom trajectories associated with dropout can help clinicians intervene to maximize outcomes. ClinicalTrials.gov Identifier: NCT01211106.

Treatment-related beliefs and reactions among trauma-focused therapy completers and discontinuers: A qualitative examination.

Prolonged exposure (PE) and cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) are effective, but some patients do not respond adequately, and dropout rates are high. Patients' beliefs about treatment and perceptions of treatment components influence treatment outcomes and may be amenable to change through intervention. The present study sought to identify beliefs and reactions to PE and CPT that differentiated completers who screened negative for a PTSD diagnosis after treatment (PTSD-), completers who screened positive for a PTSD diagnosis after treatment (PTSD+), and discontinuers who attended six or fewer sessions. Thematic analysis was used to identify themes in qualitative data collected via retrospective semistructured interviews with 51 completers (19 PTSD- after treatment, 32 PTSD+ after treatment) and 66 discontinuers of PE/CPT. Participants were demographically diverse veterans across service eras. Treatment-related beliefs and reactions differentiating these groups included perceived helpfulness of treatment, self-efficacy in engaging in treatment, anticipatory anxiety and concerns, interpretations of ongoing symptoms, and perceived consequences of treatment on functioning. Further, some patterns seemed to differ in early treatment sessions compared to during the active components of treatment. Findings point to potentially malleable targets that could be intervened upon to improve trauma-focused treatment outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Intervention recommendations to improve uptake of breast, cervical, and colorectal cancer screening among individuals living with serious mental illness.

PURPOSE: Few efforts have been made to inform intervention design for increasing the uptake of cancer screening in individuals living with serious mental illness (ILSMI), who have lower cancer screening rates than the general population. This qualitative study explored ILSMI's and their care team member's (CTM) recommendations on the design of a breast, colorectal, and cervical cancer screening intervention for ILSMI. METHODS: Twenty-five ILSMI (mean age: 71.4 years; 60% female) and 15 CTM (mean age: 45.3 years; 80% female) were recruited through purposive sampling. Semi-structured in-depth interviews were used to collect participants' intervention suggestions. Interviews were recorded, transcribed verbatim, and imported into NVivo. Content analysis and the constant comparison method were used to analyze interview data. RESULTS: ILSMI and CTMs provided several salient recommendations. ILSMI should receive disease-specific, logistical, and screening education, and primary care staff should receive education on psychopathology. Mental health providers and patient navigators should be considered as the primary interventionist. The intervention should be delivered where ILSMI receive medical or mental health services, receive community and government services, and/or via various digital media. The intervention should improve the collaboration, communication, and coordination between primary and mental health care. Findings also pointed to the implementation of trauma-informed cancer care and integrated care models comprising mental health care and primary cancer care. CONCLUSION: These findings bring the skills, knowledge, and expertise of ILSM and their care team to intervention design for increasing colorectal, breast, and cervical cancer screening in ILSMI attending an intensive outpatient program.

Psychosocial and Economic Impacts of the COVID-19 Pandemic on the Mental Health of Veteran Men and Women.

Purpose: The psychosocial impacts of the coronavirus disease-2019 (COVID-19) pandemic on women Veterans' mental health compared to men are understudied, with few studies examining the differential impact of COVID-19 stressors on depression and post-traumatic stress disorder (PTSD). Furthermore, little is known about whether social support may buffer against adverse pandemic-related outcomes for this population. In the present study, we examined (1) gender differences in the impact of the COVID-19 pandemic on numerous life domains, including economic, work, home, social, and health; (2) how pandemic impacts in these domains were associated with depression and PTSD symptoms; and (3) whether social support buffered against worse mental health outcomes. Materials and Methods: Data from 1530 Veterans enrolled in the Longitudinal Investigation of Gender, Health, and Trauma (LIGHT) study were analyzed using descriptive statistics and multiple groups' path analyses. Results: Women reported higher pandemic impact scores across life domains. For both men and women, higher health impacts were associated with increased PTSD symptoms; differential findings emerged for depressive symptoms. Home and economic impacts were associated with increased depression for both men and women, social and health impacts were associated with depression for women, and work impacts were associated with depression for men. Higher social support was associated with decreased depressive symptoms for both men and women; however, social support moderated the relationship between pandemic impacts and both PTSD and depressive symptoms for women only. Conclusions: Findings highlight the value of social support in mitigating effects of pandemic-related stress, particularly for women Veterans.

Psychiatric Issues in Women Veterans.

Women veterans have unique life experiences and mental health needs, perhaps in part related to their high rates of exposure to traumatic events including military sexual trauma, combat trauma, and intimate partner violence. We review mental health difficulties among women veterans and describe related functional impairment. Evidence-based treatments are available, but barriers to care remain, including providers' lack of awareness of the unique needs of women veterans. Efforts are needed to increase access to evidence-based interventions, remove barriers to care, and improve provider competency working with this population to maximize clinical outcomes.

Examining emotional processing theory and predictors of outcome in prolonged exposure for PTSD.

Prolonged exposure (PE) is an empirically supported treatment for posttraumatic stress disorder (PTSD). The current study examined multiple facilitators and indicators of emotional processing to identify key predictors of outcome in PE using observational coding methods. Participants were 42 adults with PTSD who received PE. Video recordings of sessions were coded to capture negative emotion activation, negative and positive trauma-related cognitions, and cognitive rigidity. Two variables emerged as predictors of PTSD symptom improvement assessed via self-report, but not clinical interview: a greater decrease in negative trauma-related cognitions and lower average cognitive rigidity. Peak emotion activation, reductions in negative emotions, and increases in positive cognitions did not predict PTSD improvement (self-report or clinical interview). Findings contribute to growing evidence highlighting the importance of cognitive change as part of emotional processing and as a key ingredient of PE, beyond activation and reduction in negative emotions. Implications for evaluating emotional processing theory and for clinical practice are discussed.

A systematic review of literature examining mediators and mechanisms of change in empirically supported treatments for posttraumatic stress disorder.

Despite the availability of empirically supported treatments (ESTs) for posttraumatic stress disorder (PTSD), relatively little is known regarding these treatments' mechanisms of change. This systematic review moves beyond previous reviews by summarizing the findings and reviewing the methodological quality of literature that specifically examined mediators/mechanisms of change in ESTs for PTSD. Studies were included if they were written in English, empirical, peer-reviewed, claimed to study mediators/mechanisms of a recommended PTSD treatment, measured the mediator/mechanism during or before and after treatment, and included a posttreatment PTSD or global outcome (e.g., functioning). PsycINFO and PubMed were searched on October 7, 2022. Two coders screened and coded studies. Sixty-two eligible studies were identified. The most consistent mediator/mechanism was reduction in negative posttraumatic cognitions, followed by between-session extinction and decreased depression. Only 47% of studies measured the mediator/mechanism before the outcome and measured the mediator/mechanism and outcome at least three times, and 32% also used growth curve modeling to establish temporal precedence of change in the mediator/mechanism and outcome. Many of the mediators/mechanisms examined had weak or no empirical support. Results highlight the need for improved methodological rigor in treatment mediator and mechanism research. Implications for clinical care and research are discussed. PROSPERO ID: 248088.

The Relative Impact of Different Types of Military Sexual Trauma on Long-Term PTSD, Depression, and Suicidality.

Sexual assault and harassment in the U.S. military are very common. Military sexual trauma (MST) is defined as sexual assault or harassment experienced during military service; yet, the relative impact of sexual assault, harassment, and their combination is not well understood. Given the extent and potential severity of the long-term outcomes of MST, it is critical to evaluate the relative impacts of these types of MST on long-term mental health outcomes. Veterans (n = 2499; 54% female) completed self-report measures of experiences of sexual assault and harassment perpetrated by coworkers during military service, posttraumatic stress disorder (PTSD), depression, and suicidality. Controlling for combat exposure, all types of MST experiences (Harassment Only, Assault Only, or Both) compared to No MST predicted greater severity of PTSD, depression, and suicidality after military service. Compared to Veterans with No MST, those who experienced Both Assault and Harassment reported significantly more severe PTSD, depression, and suicidality followed by Harassment Only, and then Assault Only. Data suggest that different types of MST experiences have an impact on long-term mental health outcomes, and the combination of Both sexual Assault and Harassment is particularly deleterious.

Leveraging observational data to identify in-session patient and therapist predictors of cognitive processing therapy response and completion.

Cognitive processing therapy (CPT) is an evidence-based treatment for posttraumatic stress disorder (PTSD), but little is known about in-session process variables that predict symptom reduction and treatment completion during CPT. Examining potentially malleable factors that may promote or impede recovery can inform care delivery and enhance outcomes. The current study used observational ratings of CPT session recordings to examine in-session patient and therapist factors in cognitive, affective, and interpersonal domains to identify their relative contributions to predicting symptom outcomes and treatment completion. Participants were 70 adult survivors of interpersonal violence who received CPT. Predictors of better posttreatment PTSD outcomes included less patient fear, ß = .32, and less patient avoidance of engaging with the therapist, ß = .35. When using the last available PTSD score, less fear, ß = .23, and avoidance, ß = .28, continued to predict better outcomes, and more patient cognitive flexibility emerged as a stronger predictor of outcome, ß = -.33. Predictors of a higher likelihood of treatment completion included more therapist use of Socratic dialogue, OR = 6.75, and less therapist encouragement of patient affect, OR = 0.11. Patient sadness and anger and therapist expression of empathy did not predict symptom outcomes or treatment completion versus dropout. The results highlight the importance of patients' cognitions, emotions, and engagement with their therapist in CPT as well as the role of therapist behaviors in patient completion of treatment.

Using Client Narratives to Identify Predictors of Outcome in Written Exposure Therapy and Cognitive Processing Therapy.

Written exposure therapy (WET) is a brief, five-session treatment for posttraumatic stress disorder (PTSD) that aims to improve access to care. WET has been demonstrated to be an efficacious PTSD treatment with lower rates of dropout and noninferior PTSD symptom outcome compared to cognitive processing therapy (CPT), a 12-session, gold-standard treatment. To identify predictors of treatment outcome in both WET and CPT, the current study examined the content of participants' written narratives. Participants were 123 adults with PTSD who were randomly assigned to receive WET (n = 61) or CPT (n = 62). The Change and Growth Experiences Scale (CHANGE) coding system was used to code all available narratives in both treatment conditions for variables hypothesized to be relevant to therapeutic change. Linear regression analyses revealed that in WET, higher average levels of accommodated (healthy, balanced) beliefs and an increase in accommodated beliefs from the first to the final impact statement predicted better PTSD symptom outcome at 12 weeks postrandomization. In CPT, higher average levels of overgeneralized and accommodated beliefs and lower levels of avoidance expressed in the narratives predicted better PTSD outcome. There were no significant predictors of outcome in analyses of change from the first to final impact statement in CPT. These findings add to research identifying predictors of change in WET and CPT by highlighting the importance of low avoidance in CPT and of trauma-related cognitions in both CPT and WET, even though WET is a brief written intervention that does not explicitly target cognitive change.

Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout.

Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are first-line treatments for posttraumatic stress disorder (PTSD) and have been disseminated throughout the U.S. Veterans Health Administration. Treatment non-completion is common and lessens clinical effectiveness; however, prior work has failed to identify factors consistently associated with non-completion. Semi-structured interviews were conducted with a national sample of veterans who recently completed (n = 60) or did not complete (n = 66) PE or CPT. Non-completer interviews focused on factors that contributed to veterans' decisions to drop out and efforts undertaken to complete PE/CPT. Completer interviews focused on challenges faced in completing treatment and facilitators of completion. Transcripts were coded using a mixed deductive/inductive approach; constant comparison was used to identify differences between completers and non-completers. Completers and non-completers differed in the extent of treatment-specific therapist support received, therapists' flexibility in treatment delivery, the type of encouragement offered by the care team and social supports, their interpretation of symptom worsening, the perceived impact of treatment on functioning, and the impact of stressors on their treatment engagement. Treatment-specific therapist support, more patient-centered and flexible treatment delivery, leveraging the full care team, and addressing functional concerns are potential targets for PE and CPT engagement interventions.

Dental caries and anthropometrics of children living in an informal floating Amazonian community: a cross-sectional pilot study.

AIMS: Increasing evidence supports a relationship between poor oral health and growth in children. Our objective was to assess the association between the presence of dental caries and anthropometric measurements of children residing in Claverito, a floating slum community in the Peruvian Amazon. METHODS: For this cross-sectional study, presence of caries was assessed using dmft/DMFT (decayed, missing, filled teeth) scores and the SiC Index (mean dmft/DMFT of one-third of the study group with the highest caries score). Anthropometric categories for age-sex-specific z-scores for height and weight were calculated based on WHO standardized procedures and definitions. The association between SiC (measured by dmft/DMFT) and anthropometric measures was estimated using unadjusted and adjusted multivariable linear regression models. Critical value was established at 5%. RESULTS: Our study population consisted of 67 children between the ages of 1 and 18 years old. Mean age was 9.5 years old (SD: 4.5), and the majority were female (52.2%). Almost all had dental caries (97.0%) and the mean dmft/DMFT score was 7.2 (SD: 4.7). The SiC Index of this population was 9.0. After adjusting for confounding variables, participants who had permanent dentition with the highest dmft/DMFT levels had statistically significant decreased height-for-age z-scores (HAZ) (p=0.04). CONCLUSIONS: We found an inverse linear association between SiC Index and height-for-age z-scores (HAZ) among children living in poverty in a floating Amazonian community in Peru. Children from under-resourced communities, like floating slums, are at high risk for oral disease possibly negatively impacting their growth and development.

Sudden Gains in Two Trauma-Focused Treatments for Posttraumatic Stress Disorder.

In the current study, we examined the degree to which sudden gains (large, rapid, and stable symptom reduction in a one-session interval) predicted treatment outcome in adults randomized to two different trauma-focused treatments. Adults diagnosed with PTSD were randomized to either written exposure therapy (WET; n = 63), a brief, exposure-based treatment for posttraumatic stress disorder (PTSD), or the more time-intensive Cognitive Processing Therapy (CPT; n = 63). Findings showed that 20.6% of participants who received WET and 17.5% of participants who received CPT experienced sudden gains. Sudden gains occurred earlier in WET (M session = 2.69, SD = 0.75) than in CPT (M session = 5.64, SD = 3.01). However, there were no treatment condition differences in the magnitude of the sudden gains. Treatment outcomes were significantly better for those who experienced sudden gains compared with those who did not, regardless of treatment assignment. Exploratory analyses of participants' trauma narratives revealed that expressing more negative emotion predicted the occurrence of sudden gains in both treatment conditions. Negative beliefs about the self and others did not predict sudden gains. The findings are discussed in terms of how they may help identify individual early response patterns that predict outcomes in trauma-focused treatments.

Dental caries and anthropometrics of children living in an informal floating Amazonian community: a cross-sectional pilot study

Abstract Aims: Increasing evidence supports a relationship between poor oral health and growth in children. Our objective was to assess the association between the presence of dental caries and anthropometric measurements of children residing in Claverito, a floating slum community in the Peruvian Amazon. Methods: For this cross-sectional study, presence of caries was assessed using dmft/DMFT (decayed, missing, filled teeth) scores and the SiC Index (mean dmft/DMFT of one-third of the study group with the highest caries score). Anthropometric categories for age-sex-specific z-scores for height and weight were calculated based on WHO standardized procedures and definitions. The association between SiC (measured by dmft/DMFT) and anthropometric measures was estimated using unadjusted and adjusted multivariable linear regression models. Critical value was established at 5%. Results: Our study population consisted of 67 children between the ages of 1 and 18 years old. Mean age was 9.5 years old (SD: 4.5), and the majority were female (52.2%). Almost all had dental caries (97.0%) and the mean dmft/DMFT score was 7.2 (SD: 4.7). The SiC Index of this population was 9.0. After adjusting for confounding variables, participants who had permanent dentition with the highest dmft/DMFT levels had statistically significant decreased height-for-age z-scores (HAZ) (p=0.04). Conclusions: We found an inverse linear association between SiC Index and height-for-age z-scores (HAZ) among children living in poverty in a floating Amazonian community in Peru. Children from under-resourced communities, like floating slums, are at high risk for oral disease possibly negatively impacting their growth and development.

Resumo Objetivos: Há cada vez mais evidências apoiando uma relação entre a saúde bucal precária e o crescimento das crianças. Nosso objetivo foi avaliar a associação entre a presença de cárie dentária e medidas antropométricas de crianças residentes em Claverito, uma comunidade flutuante de favelas na Amazônia peruana. Métodos: Para este estudo transversal, a presença de cárie foi avaliada utilizando os escores dmft/DMFT (dentes cariados, ausentes, preenchidos) e o Índice SiC (média dmft/DMFT de um terço do grupo de estudo com a maior pontuação de cárie). As categorias antropométricas para pontuações z específicas de idade e sexo para altura e peso foram calculadas com base nos procedimentos e definições padronizados da OMS. A associação entre SiC (medido por dmft/DMFT) e medidas antropométricas foi estimada usando modelos de regressão linear multivariável não ajustados e ajustados. O valor crítico foi estabelecido em 5%. Resultados: A população do estudo consistia de 67 crianças entre 1 e 18 anos de idade. A idade média era de 9,5 anos (DP: 4,5), e a maioria era do sexo feminino (52,2%). Quase todas tinham cárie dentária (97,0%) e a média da pontuação dmft/DMFT foi de 7,2 (DP: 4,7). O índice SiC desta população era de 9,0. Após ajuste para variáveis confusas, os participantes que tinham dentição permanente com os níveis mais altos de dmft/DMFT tinham diminuído estatisticamente a pontuação z de altura por idade (HAZ) (p=0,04). Conclusões: Encontramos uma associação linear inversa entre o Índice SiC e as pontuações z de altura por idade (HAZ) entre crianças que vivem na pobreza em uma comunidade amazônica flutuante no Peru. Crianças de comunidades com poucos recursos, como favelas flutuantes, correm alto risco de contrair doenças orais, possivelmente impactando negativamente seu crescimento e desenvolvimento.

Paycheck Protection Program (PPP) COVID-19 relief funding for veteran-, minority-, and women- owned dental businesses: A cross-sectional study.

Background: The Covid-19 pandemic exacerbated dental staffing shortages, which impact care delivery and ultimately oral health equity. Federal funding efforts like the Paycheck Protection Program (PPP) sought to aid traditionally underserved businesses including those owned by veterans, minority racial and ethnic groups, and women. Objectives: (1) To examine differences in PPP funding between veteran- and nonveteran-owned dental care delivery businesses and organizations and (2) to analyze other relevant factors associated with variation in PPP funding levels for dental businesses. Methods: Using publicly available PPP data, we ran unadjusted bivariable and adjusted multivariable linear regression models to estimate associations between loan approval amount and forgiveness amount, veteran status, and relevant covariates. Results: Minority racial and ethnic groups and women received less PPP funding and less loan forgiveness, on average, compared with non-minority groups. In the adjusted model with no missing self-reported demographic observations at p < 0.10, veterans received more PPP funding and loan forgiveness, on average, compared to non-veterans. Conclusion: To our knowledge, this is the first comprehensive analysis of all dental recipients of PPP funding throughout the United States. Despite PPP program intentions and strategies, traditionally underserved dental businesses did not receive increased funding to support employment.

Comparing Latino Community Members' and Clinical Staff's Perspectives on Barriers and Facilitators to Colorectal Cancer Screening.

Latinos in the United States have low rates of colorectal cancer (CRC) screening even though CRC is the third leading cause of cancer death among Latinos. This qualitative study aimed to understand and compare the perspectives of clinical staff (CS) and Latino community members (LCMs) in an urban Southern California community regarding barriers and facilitators of CRC screening. Through purposive sampling, 39 LCMs (mean age: 59.4 years, 79.5% female) were recruited to participate in one of five focus groups, and 17 CS (mean age: 38.8 years, 64.7% female) were recruited to participate in semi-structured in-depth interviews, along with a demographic survey. Interviews and focus group recordings were transcribed verbatim, translated, and analyzed using direct content analysis. Demographic data were summarized using descriptive statistics. Findings suggest that CS and LCMs have both similar and opposing perspectives with regard to barriers and facilitators of CRC screening. Themes discussed included attitudes towards CRC screening, CRC knowledge, access to resources, commitments and responsibilities, social support, vicarious learning, patient-provider communication, trust, and social relationships. Study findings can be used to guide interventions and policies to improve access to CRC screening among LCMs.

Processes of Change in Trauma-Focused Cognitive Behavioral Therapy for Youth: An Emotional Processing Theory Informed Approach.

This study examines processes of change in trauma-focused cognitive behavioral therapy (TF-CBT) delivered to a community sample of 81 youth. Emotional processing theory (EPT) is used as an organizational framework. EPT highlights activating and changing pathological trauma-related responses and increasing adaptive responses across cognitive, emotional, behavioral, and physiological domains. We coded sessions during the trauma processing phase of TF-CBT to examine the extent to which pathological and adaptive trauma-related responses were activated across domains. Higher scores indicate that more domains (0-4) were activated at a threshold of moderate to high intensity. Curvilinear change (inverted U, increase then decrease) in multimodal negative response scores across sessions predicted improvement in internalizing and PTSD symptoms at posttreatment. Linear increases in multimodal positive responses predicted improvement in externalizing symptoms. Findings suggest value in activating and changing both pathological and adaptive trauma responses across multiple domains and examining nonlinear patterns of change.