First responders face elevated risks of developing mental health conditions due to frequent exposure to potentially traumatic events. However, access to appropriate care is often limited by systemic, cultural, and logistical barriers. This article presents a novel, coproduced model of mental health service delivery tailored to the unique needs of first responders, implemented through the Responder Assist program in Victoria, Australia. Responder Assist was developed using coproduction principles, integrating lived experience with clinical expertise and research evidence. The service includes centralized intake, access to specialized trauma-informed providers, and delivery of evidence-based therapies, supported by clinician supervision and continuous quality improvement processes. To provide early insights into service impact, we conducted preliminary, naturalistic analyses of 109 current and former first responders (M-age = 49.7 years, SD = 10.1; 75.2% male) enrolled between March 2021 and May 2025. Outcomes were assessed at baseline, 3 months into treatment, and discharge using repeated-measures analyses. Preliminary outcome data indicate promising reductions in symptoms of posttraumatic stress disorder, psychological distress, symptoms of major depressive disorder, and symptoms of generalized anxiety disorder, as well as modest improvements in functional disability and anger. These findings suggest that the model may effectively address barriers to care and improve mental health outcomes for first responders. This population-specific, trauma-informed service model demonstrates the value of integrating lived experience and coproduction in mental health service design. It offers a replicable framework for improving access and outcomes in trauma-exposed workforces. Future initiatives should consider similar approaches to enhance relevance, engagement, and effectiveness of care.
Childhood trauma has far-reaching effects on adult health, shaping emotional motivations for food choices and increasing the risk of maladaptive eating behaviors and related physical and psychological consequences. Objective: This study examined the effects of childhood trauma on emotional eating, focusing on the mediating roles of attachment quality and emotional distress (anxiety and depressive symptoms) in an integrative model. Method: A sample of 500 participants from the general population completed self-report measures (Childhood Trauma Questionnaire, Adult Attachment Scale, Hospital Anxiety and Depression Scale, and the Food Choice Determinants Questionnaire). Data analysis was conducted using the IBM SPSS Statistics for Windows. To evaluate the proposed model, structural equation modeling, utilizing AMOS software and using the maximum likelihood estimation method was used. Multiple-step mediation analyses with bootstrapped confidence intervals tested indirect effects. Results: Childhood trauma predicted higher attachment anxiety and lower attachment closeness, which increased anxiety distress symptoms and, in turn, higher emotional motivations for food choices. Anxious attachment also had a direct effect, whereas depressive symptoms did not mediate the relationship. Conclusions: These findings underscore the critical role of relational and affective mechanisms in the pathways linking early trauma to emotional eating. Interventions that integrate attachment-informed therapy, emotion regulation training, and nutritional guidance may more effectively address maladaptive eating behaviors and reduce related health risks. The study advances theoretical understanding and practical insights for prevention and intervention in trauma-exposed populations.
Bereavement can profoundly disrupt an individual's assumptive world and provide a context for posttraumatic growth (PTG). However, most individuals experience grief and distress alongside perceptions of PTG. The positive relationship between posttraumatic stress (PTS) symptoms and PTG has raised questions about the adaptive significance of PTG. This cross-sectional study used a sample of bereaved Icelandic adults who identified the death of a loved one as their most traumatic life event (n = 257), of which 58.8% identified as women. We aimed to (a) assess the prevalence of moderate-to-high levels of PTG, (b) examine the associations between perceived PTG and PTS symptoms, and (c) explore PTG perceptions and PTS symptoms based on the time since bereavement to better understand the potential role of PTG and its co-occurrence with distress following loss. Approximately 39% of participants reported moderate-to-high PTG. There was a small positive association between PTG and PTS scores, with intrusions and arousal/reactivity showing consistent relationships across PTG domains, supporting the importance of rumination for PTG. Individuals bereaved 5-10 years earlier showed slightly higher perceived PTG and lower PTS than those with more recent losses, although both declined when more than 10 years had passed. Time since loss did not moderate the PTG-PTS association, suggesting that growth and distress tend to co-occur. Therefore, PTG reflects ongoing cognitive engagement with the loss rather than a later resolution of distress that diminishes as adaptation progresses, a conclusion that warrants longitudinal confirmation, but is well-supported by the patterns observed here.
First responders are routinely exposed to high levels of stress and traumatic events, placing them at increased risk for mental health difficulties and sleep disturbances. Although perceived stress and trauma exposure have been linked to insomnia, the mechanisms underlying these relationships remain unclear. The current exploratory study was undertaken in South Africa and examined the relationship between perceived stress, exposure to potentially traumatic events, and insomnia among first responders. In addition, the study investigated the role of indices of psychological distress in this relationship. Participants (n = 429) were first responders who completed the Perceived Stress Scale, the Life Events Checklist, the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, the posttraumatic stress disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition, and the Insomnia Severity Index. The results of path analysis indicated that depression and PTSD fully mediated the relationships between perceived stress and traumatic events, on the one hand, and insomnia, on the other hand. However, anxiety was not a significant pathway in the relationship between the adverse factors and insomnia, suggesting that its role in sleep disturbances among first responders may be distinct from that of depression and PTSD. These findings emphasize that addressing sleep disturbances in this population may require interventions targeting underlying mood and trauma-related symptoms, rather than focusing solely on stress and trauma exposure.
Posttraumatic stress disorder (PTSD) is well-documented as impacting functional impairment (FI), and research has demonstrated that clusters of PTSD symptoms as defined by the DSM-5 are differentially associated with FI domains. However, few studies have examined PTSD and complex PTSD (CPTSD) as defined by the ICD. ICD-11 PTSD consists of three symptom clusters (re-experiencing, avoidance, and sense of threat) while CPTSD consists of the three PTSD clusters as well as disturbances in self-organization (DSO) consisting of an additional three clusters (affect dysregulation, negative self-concept, and disturbances in relationships). The current study examined the use of the International Trauma Questionnaire (ITQ) PTSD and DSO subscales as predictors of functional impairment in a women veteran sample, considering the dimensional scoring of both the PTSD and DSO subscales, as well as standard diagnostic scoring for PTSD and CPTSD. Trauma symptom total was predictive of overall impairment measured by the WHODAS 2.0, and predicted impairment in difficulties getting along with people, life activities, and participating in society. The DSO subscale of the ITQ was more predictive of difficulties getting along with others. The cumulative impact of PTSD and DSO subscales uniquely contributed to life activities. Both DSO and PTSD symptoms were uniquely predictive of difficulties participating in society. Participants whose diagnostic scores were consistent with CPTSD had significantly greater FI compared to those whose diagnostic scores were consistent with PTSD. These data suggest the potential benefit of the ITQ in assessing the relative contributions of specific types of symptoms to FI.
Dissociation is a prevalent and impairing symptom commonly observed in trauma-exposed populations following interpersonal trauma. While anxiety sensitivity (AS) and emotional difficulties have been separately implicated in the development of dissociative experiences following trauma, a potential pathway underlying its development remains underexplored. This study examined the mediating effects of AS and emotional avoidance on the association between interpersonal trauma and dissociative symptoms. A trauma-exposed sample (N = 583) completed self-report measures assessing trauma exposure (LEC-5), anxiety sensitivity (ASI-3), emotional avoidance (i.e., DERS-16 nonacceptance subscale), and dissociative experiences (DES-B). Linear regression and path analytic models were conducted using R. Follow-up analyses included all domains of AS to assess specific significant contributors to dissociation. Interpersonal trauma was significantly associated with elevated AS and emotional avoidance, subsequently predicting greater dissociative symptom severity. When accounting for AS and emotional avoidance, our direct effect was no longer significant with AS and emotional avoidance fully mediating this relationship. Subdomain analyses revealed cognitive and social AS as the sole significant mediators between interpersonal trauma and dissociation via emotional avoidance. AS and emotional avoidance jointly contribute to the development of greater dissociative symptom severity following interpersonal trauma. Cognitive and social concerns emerged as key AS subdomains driving this pathway, suggesting that individuals with heightened fears of losing control or social embarrassment may display greater rates of emotional disengagement as a maladaptive coping strategy. Our findings further exemplify AS and emotional avoidance as particularly salient treatment targets for trauma-exposed populations exhibiting problematic dissociative experiences.
In this article, vicarious resilience framework is explored to acknowledge that exposure to traumatic narratives, while potentially leading to adverse outcomes, can also be a source of transformation for health care providers. Although vicarious trauma in medical settings is well-documented, vicarious resilience in medical practice and education remains critically underexplored. This article invites health care providers to rethink common misconceptions and advance toward a paradigm shift away from viewing the witnessing of suffering solely through the lens of vicarious trauma, as trauma and resilience paradoxically coexist. Cultivating vicarious resilience in medical settings recognizes that providers can experience positive psychological transformation by engaging with their patients' strength.
Sexual abuse and assault are a major public health problem with high prevalence rates and potentially negative mental health consequences. Men and masculine-identifying individuals who are members of the sexual and gender minority (SGM) community are at high risk of being sexually assaulted and face with unique barriers to seeking and engaging in mental health treatment such as structural stigma, minority stress, and mistrust of services. At the conclusion of a randomized trial of a peer-led online mental health treatment, qualitative interviews were conducted with 101 SGM male survivors about their past mental health treatment experiences and preferences for psychotherapy and pharmacotherapy. The vast majority reported that they had previously engaged briefly in formal mental health treatment, though most explained that they had never discussed trauma or related issues. Concerns regarding side effects of medication were prevalent. Barriers to psychotherapy engagement included perceived experiences of discrimination, difficulty accessing care (i.e., unsure how to find an SGM-affirmative provider, insurance, and financial cost), or perceived poor fit with the therapy or therapist. Most expressed willingness to seek treatment in the future, particularly individual psychotherapy with a licensed mental health professional. Understanding past mental health treatment experiences and preferences of this marginalized population can inform outreach as well as clinical services.
Youth exposed to traumatic experiences face a higher risk of developing mental health problems such as posttraumatic stress disorder (PTSD) and comorbid anxiety and depressive disorders. Traditional models of psychopathology conceptualize disorders as latent constructs, but this approach overlooks how symptoms interact with one another. Network theory offers a new perspective by viewing disorders as systems of interconnected symptoms, which is particularly useful for understanding comorbidity and symptom overlap across conditions like PTSD, anxiety, and depression. The present study aimed to apply network analysis to better understand comorbidity between disorders to identify key symptoms that may play a central role in maintaining psychological distress. A network analysis was conducted in R Studio with a sample of 1,191 Salvadoran youth, aged 8-18 years (M = 12.61, SD = 2.51, 54.5% female). Network analysis identified four communities based on PTSD, anxiety, and depression symptoms: (a) PTSD intrusion and avoidance, (b) PTSD negative cognitions/mood and arousal, (c) anxiety, and (e) depression. Items that showed greater centrality included negative affect, risky and destructive behavior, worry, sleep disturbances, and concentration problems. Results indicate that symptoms of PTSD, anxiety, and depression are closely interconnected and observed in the presence of groups with mixed symptoms, with specific symptoms (e.g., worry, feelings of worthlessness, sleep disturbances, concentration problems, negative affect, and risky behavior) emerging as central and influential within the network. These findings underscore the importance of transdiagnostic approaches for prevention and intervention, highlighting the need to target high centrality symptoms to disrupt symptom networks and improve mental health outcomes for trauma-exposed youth.
Posttraumatic stress disorder (PTSD) and major depressive disorder are commonly comorbid among individuals with a history of trauma exposure, and this comorbidity can have implications for functioning and treatment. There is a substantial amount of prior research examining the co-occurrence of these two diagnoses, though additional investigation into the underlying mechanisms associated with high rates of comorbidity is warranted. The present study examined PTSD symptoms, depression symptoms, and emotion dysregulation in two college student samples using a network analysis approach, which allows for examining the dynamic interplay between symptoms. Study 1 included 410 students with a history of trauma from a large Hispanic-serving institute, and Study 2 included 244 student participants with a history of trauma exposure from a Midwestern public university. Both samples indicated high central strength for the Difficulties in Emotion Regulation Scale's Limited Access to Emotion Regulation Strategies subscale, and this strategies subscale also demonstrated high expected influence in both samples. Results revealed several nonzero regularized partial correlations among PTSD symptom clusters, depression, and emotion dysregulation subscales. These findings supported PTSD and depressive symptoms as distinguishable, though connected, constructs. PTSD's negative alterations in cognition and mood cluster, depression, and the Difficulties in Emotion Regulation Scale Limited Access to Emotion Regulation Strategies subscale seemed important for understanding the comorbidity of these two diagnoses, and therefore the belief that distress is persistent and unchangeable, despite one's actions, may contribute to the development or maintenance of both PTSD and major depressive disorder.
Understanding the unique mental and physical health related experiences of male sexual assault survivors is important for helping this underserved group. The present study aimed to examine whether male survivors of sexual trauma who struggle with self-blame are more likely than other men exposed to potentially traumatic events to engage in reduced exercise and increased eating to cope with negative affect. Participants were a racially diverse sample of 639 male university students who were all directly exposed to a DSM-5 Criterion A potentially traumatic event. Of the 639 participants, 93 reported a history of sexual trauma. We hypothesized that men with sexual trauma histories would report more maladaptive health behaviors compared to men with other trauma histories, and that self-blame would moderate these associations. We found that sexual trauma, but not self-blame, was associated with reduced exercise. In addition, we found no direct effects of self-blame or sexual trauma for eating behaviors, however a significant interaction emerged whereby sexual trauma survivors with lower levels of self-blame were significantly more likely to eat to cope with negative affect. These findings highlight the complex role of trauma type and self-blame in shaping health behavior and point to considerations for clinicians working with male survivors, including the challenges some men may face in engaging in regular exercise during trauma recovery.
Occupational vicarious trauma (VT) is "secondhand" trauma transmitted to professionals who work with people who experienced trauma directly. VT symptoms are associated with burnout, depression, and turnover. Current instruments measure VT symptoms, but none identify how workers are exposed, inhibiting the development of organizational interventions. To address this gap, we developed and tested the Vicarious Occupational Trauma Exposure (VOTE) Index to measure VT exposure, frequency, and impact. First, qualitative data of substance use disorder (SUD) providers (n = 49) and VT scientific articles (n = 109) were coded to develop domains and items, modified with cognitive interviews of SUD providers (n = 19) and expert consultation (n = 9). The VOTE Index was then tested in a survey of the SUD workforce, quota sampled to reflect the US SUD workforce (n = 1,415) and resampled 2 weeks later for test-retest reliability. Using linear regression, we tested convergent and discriminant validity of weighted and unweighted versions of the VOTE and evaluated test-retest reliability with intraclass correlational coefficient (ICCs) scores. The 16-item VOTE Index included four domains: clients sharing about trauma, reviewing evidence of trauma, documenting trauma, and coworkers sharing about trauma. Both weighted and unweighted summary scores were highly correlated with psychological distress and job satisfaction measures (p < .001; convergent validity) and not significantly correlated with celebrity entertainment (discriminant validity). The VOTE demonstrated excellent test-retest reliability (ICCweighted = 0.86, ICCunweighted = 0.93). As the first instrument to measure VT exposure, the VOTE Index demonstrated strong content, convergent, and discriminant validity and excellent reliability with the SUD workforce. The VOTE Index may help develop organizational interventions to protect workers from VT.
Secondary traumatization (ST) is described as a condition that may arise from indirect trauma exposure, the symptoms mirroring those of posttraumatic stress disorder (PTSD). In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), indirect trauma exposure at work is explicitly recognized as a possible criterion A event for diagnosing PTSD and, in principle, the International Classification of Diseases, 11th Revision (ICD-11) also allows for a diagnosis of PTSD following indirect trauma exposure as long as the exposure is perceived as "extremely threatening or horrific." Nonetheless, research on ST is mostly conducted with measures that do not conform to the diagnostic requirements of PTSD in either diagnostic system, and it is unclear whether extant research on ST corresponds to a mental health problem different from PTSD. The aim of the current study is to review and test the extent to which measures of ST converge with measures of PTSD. A systematic literature search was conducted to map studies assessing the overlap of measures of ST and DSM-5 or ICD-11 PTSD. Subsequently, the overlap between Professional Quality of Life Scale Version 5, a frequently used measure of ST, and International Trauma Questionnaire, a measure of ICD-11 PTSD, was tested across four samples: municipal child welfare workers (n = 498), "Barnahus" employees (n = 63), prosecutors (n = 257), and police forensic video interviewers of children (n = 43). There were limited studies detailing the overlap between measures of ST and DSM-5 or ICD-11 PTSD, and high heterogeneity in the use of psychometric tools across the existing studies. In the analyses based on the four samples, probable rates of ST and PTSD were found to be very low. Correlation between ST and PTSD was high across the samples, and the comparability of ST and PTSD increased when using a probability-based categorization of at-risk status for ST. The results indicate important limitations to the overlap between established measures of ST and PTSD. However, more research is needed to determine whether measures of ST and PTSD are indicators of the same underlying phenomenon.
This work examines how cultural expectations of hegemonic masculinity (HM) shape the presentation of psychological distress and the challenges of recovery for men living with complex posttraumatic stress disorder. We argue that hegemonic ideals of masculine toughness, centered on emotional restraint, autonomy, and invulnerability, heighten susceptibility to identity disturbance following trauma while also obstructing access to the relational and emotional practices essential to healing. For many men, trauma is experienced simultaneously as a psychological injury and as a threat to an established masculine self. The internalization of HM norms produces shame, disconnection, and emotional repression, creating conditions in which recovery often requires forms of openness and vulnerability that contradict the masculine ideals men have been socialized to uphold. This article traces how HM functions as both a risk factor and a mode of functional resistance that shapes how trauma is experienced, narrated, and embodied. By reframing complex posttraumatic stress disorder through masculinities identity theory, we identify the need for therapeutic models that engage masculinity as an active component of trauma recovery. To address this, we introduce a masculinities-responsive clinical framework that supports the reconstruction of masculine identity as part of psychological repair: the Mapping, Interpreting, Modulating, Integrating, and Coconstructing framework. Implications for practice and future research are discussed.
Anhedonia has been recognized as an independent symptom cluster based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition posttraumatic stress disorder (PTSD) criteria, yet it is excluded from International Classification of Diseases, 11th Revision criteria. Although fear-based mechanisms are well-established, the specific role of anhedonia in driving symptom dynamics remains undercharacterized. This longitudinal study aimed to investigate the temporal influence of anhedonia on the progression of distinct PTSD symptom clusters in trauma-exposed youth. From an initial baseline sample of 836 youths exposed to an explosion, 794 provided data for at least one follow-up assessment at 8 or 13 months. Multivariate cross-lagged panel models (N = 794) examined directional relationships, whereas latent difference score models (restricted to N = 659 participants completing all three waves) assessed the influence of anhedonia on symptom change rates. Cross-lagged analyses showed that anhedonia significantly predicted subsequent increases in avoidance (p < .001) and negative affect symptoms (p = .002). The latent difference score model further indicated that anhedonia predicted a greater rate of increase in negative affect symptoms (p < .05), but not avoidance symptoms. In conclusion, our findings suggest that anhedonia plays a potential role in the exacerbation of negative affect and the maintenance of avoidance symptoms. Specifically, anhedonia appears to accelerate the rate of negative affect increase and sustain avoidance, while showing weaker associations with fear-based symptoms. These results highlight the importance of anhedonia in PTSD symptom progression among youth and support its retention in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition framework. Clinically, early interventions targeting anhedonia could represent a valuable strategy to disrupt the escalation of negative affect and support recovery in this population.
Batterer Intervention Programs (BIPs) are the current standard of care for men who use intimate partner violence (IPV). BIPs focus on reshaping men's maladaptive beliefs regarding IPV, women, and gender stereotypes. However, group-based BIPs have mixed empirical support. Fathers for Change (F4C) is a father-focused intervention with promising initial outcomes that takes an individualized and family-centered approach, emphasizing reflective functioning and emotion regulation. The current study leveraged data from a small randomized controlled trial (RCT) that reported greater reductions in self-reported IPV in men who received individually delivered BIP (BIP-I) and F4C compared to a traditional group-based BIP. An observational coding system was applied to video-recorded therapy sessions to examine in-session variables hypothesized to predict father self-reported IPV and emotion dysregulation. The sample included 50 treatment-seeking fathers with a recent history of IPV and child protective services involvement (BIP-I: n = 24; F4C: n = 26). Multigroup SEM analyses revealed different predictors of IPV behaviors in BIP-I and F4C. In BIP-I, none of the variables predicted post-treatment IPV, whereas in F4C, less avoidance and more cognitive emotional processing during sessions predicted greater reductions in IPV. Unexpectedly, more rigidity was associated with more improvement in IPV behavior, whereas higher self-efficacy was associated with less improvement. No significant predictors of emotion regulation emerged in either treatment. These findings highlight the importance of examining in-session variables in IPV treatments for fathers, with implications for refining interventions and guiding future research.
As the trauma literature begins to incorporate multicultural, feminist, womanist, and strength-based approaches and ideas, research is shifting from a focused examination of PTSD to a more holistic view that includes studies examining both distress- and growth-related factors (Bryant-Davis & Comas-Diaz, 2016). To this end, a longitudinal community sample of African American adult women survivors of sexual assault (n = 506) was used to examine how various background and post-assault factors related to changes in posttraumatic growth (PTG) over three years, using mixed model regression analyses. Analyses showed that increases in social support and greater total number of traumatic life events were associated with significant increases in PTG levels. Greater characterological self-blame was related to lower average PTG. Seeking counseling following the assault, behavioral self-blame and wave were not significant predictors of changes in PTG. Implications for culturally responsive interventions are provided.
This study examined how continuity and change resilience processes explain the relationship between recovery-focused individual disaster communication (IDC; Spialek & Houston [2018, Communication Research, 45(6), 934-955]) and posttraumatic stress (PTS). By surveying 418 Arkansas and Tennessee residents impacted by a 2023 tornado outbreak, results revealed more recovery-focused IDC was associated with more PTS. In addition, recovery-focused IDC was indirectly related to more PTS through the resilience process of reframing. However, IDC focused on assisting with disaster recovery indirectly reduced PTS through the resilience process of affirming identity anchors. Overall, the results (a) reveal the ways in which recovery-focused IDC may help disaster-impacted individuals cope and (b) offer recommendations to incorporate IDC and resilience processes into disaster mental and behavioral health frameworks.
Research shows that sexual assault (SA) can impact survivors' informal social network members (e.g., friend, family member, romantic partner), who are the most frequently told persons about the assault by women-identified survivors. However, little qualitative work has investigated the impacts on informal support providers (SPs) receiving disclosures of alcohol/drug-related assault, an understudied form of SA. The current qualitative interview study examines the impacts of SA disclosures on informal SPs (N = 27) drawn from a dyadic survivor-SP interview sample using descriptive thematic analysis. Impacts on SPs and their help seeking related to the survivors' alcohol/drug-related SA disclosure included: emotional effects, cognitive and behavioral effects, and impacts on their decisions to seek help from other informal and formal SPs. Implications for research, clinical treatment, and intervention targeting informal SPs of survivors are drawn.
Chronic, non-malignant musculoskeletal pain (CP) and posttraumatic stress disorder (PTSD) frequently co-occur. Insomnia disorder is common among individuals with pain and PTSD and negatively affects physical and mental health. Specifically, insomnia disorder may contribute to the overall complexity, course, and severity of CP/PTSD, leading to a vicious cycle of chronic insomnia and worse symptom severity. We present secondary analyses of cross-sectional self-report data collected using VA eScreening from N = (3,937) post-9/11 Veterans enrolling for VHA healthcare. Our sample had a mean age of 35.5 years old (SD = 9.0), primarily male (82%), and more than half of the sample was non-Latino/Hispanic (69.5%) and White (64.2%). We analyzed measures of insomnia (Insomnia Severity Index; ISI), pain severity and interference (PROMIS), and PTSD symptoms (PTSD Checklist; PCL). ISI, PROMIS, and PCL were all positively correlated (p’s <.05; ES’s >.44). The ISI had an indirect effect on the association between PTSD and both pain severity (indirect effect =.04, SE =.002, 95% CI [.0312,.0389]) and pain interference (indirect effect =.09, SE =.005, 95% CI [.0765, 0952]). Screening and treating insomnia disorder, in the context of co-occurring PTSD and complex pain disorder is clinically important and may help increase overall quality of life in a high-risk and diverse population. Future studies underway by the VA Center of Excellence Sleep Research Consortium and elsewhere examine relationships among and treatments for sleep disorders, chronic pain, and PTSD and include objective measurement of pain sensitivity, pain interference, and sleep disorders (e.g., polysomnography; actigraphy) when feasible.
