DSM + HiTOP Criteria Flashcards
1
Q
What are the six main factors (i.e., spectra) of the HiTOP model + what do they mean?
A
- Somatoform (excessive focus on physical symptoms and health concerns)
- Internalizing (disorders characterized by distress, fear, and anxiety)
- Detachment (social withdrawal, anhedonia, and emotional coldness)
- Thought disorder (disorders involving psychosis, cognitive disorganization, and unusual thinking)
- Antagonistic externalizing (interpersonal hostility, aggression, and exploitation of others)
- Disinhibited externalizing (impulsivity, irresponsibility, and behavioral disinhibition)
2
Q
What are the 4 subfactors of the internalizing spectra?
A
- Sexual problems
- Eating pathology
- Fear
- Distress
3
Q
There are two subfactors that fall under two spectra simultaneously, which are these?
A
- Mania (internalizing + thought disorder)
- Antisocial behaviour (disinhibited externalizing + antagonistic externalizing)
4
Q
What do the subfactors under each spectra of HiTOP indicate?
A
They are specific parts of the spectra, that are highly correlated with each other (e.g., people with fear often experience sexual problems)
5
Q
Which disorders, that have to be learned for the partial, are not included in HiTOP?
A
ASD, dissociative disorders, acute stress and converson
6
Q
Which two syndromes fall under neurodevelopmental disorder?
obviously, there are more, these are just for the partial
A
- Autism Spectron Disorder
- ADHD
7
Q
Which five disorders fall under Schizophrenia Spectrum and other Psychotic Disorder?
A
- Delusional Disorder
- Brief Psychotic Disorder
- Schizophreniform
- Schizophrenia
- Schizoaffective
8
Q
Which two disorders + three types of episodes fall under Bipolar and Related Disorders?
A
- Bipolar 1
- Bipolar 2
- Manic episode
- Hypomanic episode
- Depressive episode
9
Q
Which specifier can be given to both bipolar and depressive disorders? If this specifier is given, to what HiTOP spectra does it relate?
A
with psychotic features - thought disorder
10
Q
Which two disorders fall under Depressive disorders?
A
- Major depressive disorder
- Persistent depressive disorder
11
Q
What five disorders + one specifier fall under Anxiety disorders?
A
- Specific phobia
- Social anxiety
- Panic disorder
- Agoraphobia
- Generalized anxiety disorder
- Panic attack specifier
12
Q
What three disorders fall under Trauma-related disorders?
A
- PTSD
- Acute stress disorder
- Adjustment disorder
13
Q
Three disorders under dissociative disorders?
A
- DID
- Dissociative amnesia disorder
- Depersonalization/derealization disorder
14
Q
Three disorders under Somatic symptom and related disorders?
A
- Somatic Symptom disorder
- Illness anxiety disorder
- Conversion disorder
15
Q
Two disorders under Eating disorders?
A
- Anorexia Nervosa
- Bulimia Nervosa
16
Q
Two disorders under Disruptive, impulsive and control disorders?
A
- Oppositional-Defiant disorder
- Conduct disorder
17
Q
What are the criteria of ASD? Both criteria
A
Persistent deficits in social communication/interaction, across multiple contexts (all of the following need to apply)
1. Deficits in social-emotional reciprocity
2. Deficits in non-verbal communication
3. Deficits in developing/maintaining and understanding relationships
Restricted, repetitive patters of behaviour, interests or activities (two of the following need to apply)
1. Stereotyped or repetitive motor movements, use of objects, or speech
2. Insistence on sameness, adherence to strict routines or ritualized patterns of verbal/non-verbal behaviour
3. Highly restricted, fixated interests that are abnormal in intensity or focus
4. Hyper- or hypo-activity to sensory input or unusual interest in sensory aspects of the environment
18
Q
Specifiers of ASD?
A
- Very substantial support (severe social communication deficits & extreme inflexibility)
- Substantial support (marked deficits social, difficulty with change)
- Support (without support, deficits cause impairments & inflexibility is noticeable)
19
Q
To what specta does ASD relate in the HiTOP?
A
Trick question bitchh, none
20
Q
Symtpoms of ADHD? Inattention part
A
A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning/development (1 and/or 2 need to apply)
~~~
```
Inattention = 6+ need to have persisted for 6 months+ (impairment and inconsistent with developmental level), 5+ for adolescents and adults over the age 17. (not a result of not understanding instruction or oppositional behaviour). Note: most have often infront
1. Fails to give close attention to details or makes careless mistakes in schoolwork, work, etc.
2. Difficulty in sustaining attention in tasks/play
3. Does not seem to listen when spoken to
4. Not following through on instructions and fails to finish tasks (e.g., homework, chores)
5. Difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; messy/disorganized)
6. Avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
7. Loses things (necessary for tasks or activities)
8. Easily distracted by external stimuli (includes thoughts)
9. Forgetful in daily activities (chores, bills, etc.)
21
Q
Symptoms of ADHD? Hyperactive-impulsive
A
Hyperactivity and impulsivity = 6+, 6 months+ (same applies as with inattention), 5+ for 17+
1. Fidgeting/squirming/etc.
2. Leaves seat in situations where seating is expected
3. Runs and climbs in situations inappropriate (restlesness in adolescents and up)
4. Unable to play/engage in leisure activities quitely
5. “on the go” or “driven by a motor” (unable or uncomfortable being still for extended amount of times = experienced by others as restless or difficult to keep up with)
6. Talks excessively
7. Blurts out answers, finishes sentences, etc.
8. Difficulty waiting in line/their turn
9. Interrupts/intrudes on others
22
Q
ADHD on HiTOP?
A
Disinhibited Externalizing
23
Q
Symptoms delusional disorder?
A
Presence of one+ delusions with a duration of month+
24
Q
Difference between hallucinations and delusions?
A
Hallucinations = Sensory experiences that are not actually there (false perceptions)
Delusions = False beliefs held even in the face of contrary evidence (false thoughts)
25
Which four DSM disorders fall under the thought disorder spectra of HiTOP?
1. Delusional disorder
2. Brief psychotic disorder
3. Schizophreniform disorder
4. Schizophrenia
26
Schizoaffective disorder HiTOP?
Thought disorder, with subfactor mania
27
Symptoms brief psychotic disorder?
Presence of **1+** of the following, at least **1 OR 2 OR 3** has to be present
1. Delusions
2. Hallucinations
3. Disorganized speech (derailment, incoherence)
4. Disorganized or catatonic behaviour
Duration of an episode (of disturbance above) 1 day-month and eventual full return to premorbid level of functioning
28
What is meant by disorganized and catatonic behaviour?
Disorganized = Unpredictable, inappropriate or purposeless behaviour (e.g., dressing oddly, acting bizare, trouble with goal-directed tasks)
Catatonic = Extreme motor disturbances (rigid immobility or excessive movement)
29
Schizophreniform disorder symptoms?
**2+** of the following, present for a significant portion of a month (or less if treated). One of these **has to be 1, 2 or 3**
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Disorganized or catatonic behaviour
5. Negative symptoms (diminished emotional expression or avolition)
An episode lasts 1-6 months, when diagnosis is made before recovery of episode, qualify as "provisional".
| latter bc you do not know how long it will last?
30
What does avolition mean?
A lack of interest/engagement in goal-directed behaviour
31
Schizophrenia symptoms?
**2+** of the following, present for a significant portion of a month (or less if treated). One of these **has to be 1, 2 or 3**
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Disorganized or catatonic behaviour
5. Negative symptoms (diminished emotional expression or avolition)
For significant portion of time, since start. Level of functioning in one+ area (work, interpersonal, etc.) is below prior onset (if childhood; below expected)
**6+ months** of continuous signs, **must include 1+ month of symptoms meeting criterion A** (6+ can include prodromal or residual symptoms). **In prodromal/residual, symptoms may only be negative or 2+ others in reduced form.**
32
Symptoms schizoaffective disorder?
1. Uninterrupted period of illness during which there is a major mood episode (depressive or manic), **concurrent with schizophrenia criterium A**
2. Delusions or hallucinations for 2+ weeks in the absence of major mood episode during the lifetime duration
3. Symptoms that meet criteria for major mood episode are present for the majority of total duration of active and residual portions of the illness
33
Bipolar I symptoms?
Criteria for at least one manic episode (A-C)
| see: not necessarily depressive episode
34
Bipolar II symptoms?
Criteria have been met for at least one hypomanic episode (A-D) and at least one major depressive episode (A)
35
Criteria of a manic episode?
A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally persistently increased activity or energy for **1+ week** (present most of the day, almost every day)
During period of above, **3+ symptoms (4+, if mood is only irratable)** present, significantly and differing from normal
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative or pressure to keep talking
4. Flight of ideas or subjective experiences that thoughts are racing
5. Distractibility
6. Increase in goal-directed activity or psychomotor agitation (purposeless non-goal directed)
7. Excessive involvement in activities that have a high potential for painful consequences (could also include things like shopping sprees, foolish investments)
Mood sufficiently severe to cause impairment in social or occupational functioning (or to necessitate hospitalization), or there are psychotic features
36
Criteria of hypomanic episode?
A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally persistently increased activity or energy for **4+ days** (present most of the day, almost every day)
During period of above, **3+ symptoms (4+, if mood is only irratable**) present, significantly and differing from normal
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative or pressure to keep talking
4. Flight of ideas or subjective experiences that thoughts are racing
5. Distractibility
6. Increase in goal-directed activity or psychomotor agitation (purposeless non-goal directed)
7. Excessive involvement in activities that have a high potential for painful consequences (could also include things like shopping sprees, foolish investments)
Episode associated with a change in functioning that is uncharacteristic
Disturbance and change noticeable to others
37
What is something a manic episode can include that a hypomanic episode cannot?
Psychotic features
38
Criteria major depresside episode?
**5+** of the following, same **2-week period** and represent change from previous functioning, **1 or 2 has to be present**
1. Depressed mood (sad, empty, hopeless, irratable in children/adolescents), can be observed by others or self-report
2. Diminished interest or pleasure in activities
3. Significant weight change (when not actively trying to) or change in appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation (has to be observable)
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate, or indecisiveness
9. Recurrent thoughts of death, recurrent suicidal ideation or suicide attempt/plan
39
Bipolar I and II HiTOP?
Internalizing and thought disorder, with subfactor mania
40
Symptoms major depressive disorder?
The ones we have to learn are the same as that of a depressive episode (it cannot include manic/hypomanic episode). To reiterate:
**5+** of the following, same **2-week period** and represent change from previous functioning, **1 or 2 has to be present**
1. Depressed mood (sad, empty, hopeless, irratable in children/adolescents), can be observed by others or self-report
2. Diminished interest or pleasure in activities
3. Significant weight change (when not actively trying to) or change in appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation (has to be observable)
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate, or indecisiveness
9. Recurrent thoughts of death, recurrent suicidal ideation or suicide attempt/plan
41
Major depressive disorder (MDE) HiTOP?
Internalizing, with subfactor distress
42
Symptoms persisten depressive disorder?
Depressed mood for most of the day, **2+ years (in children/adolescents 1+ year)**
While depressed, **2+** of the following
1. Poor appetite of overeating
2. Insomnia or hypersomnia
3. Low energy or fatique
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness
43
Four specifiers for PDD?
1. Pure dysthymic = full criteria for MDE have not been met in the past 2+ years
2. Persistent MDE = full criteria of MDE have been met in the past 2+ years
3. Intermittent MDE, with current episode = full criteria MDE are currently met, but periods of 8+ weeks in the past 2+ years without meeting full criteria of MDE
4. Intermittent MDE, without current episode= full criteria MDE not currently met, but 1+ MDE in the past 2+ years
44
Persistent depressive disorder HiTOP?
Internalizing, with subfactor distress
45
Which four DSM disorders fall under the spectra internalizing, with subfactor fear of the HiTOP?
1. Specific phobia
2. Social anxiety disorder
3. Panic disorder
4. Agoraphobia
46
GAD HiTOP?
Internalizing, with subfactor distress
47
Symptoms specific phobia?
1. Marked fear or anxiety about a specific object or situation (in children, this may be expressed as crying, tantrums, freezing or clinging)
2. The phobic object or situation almost always provokes immediate fear or anxiety
3. The phobic object or situation is actively avoided or endured with intense fear or anxiety
4. Fear or anxiety is out of proportion to the actual danger posed and sociocultural context
5. Fear, anxiety or avoidance is persistent, typically lasting for **6+ months**
48
Symptoms SAD?
1. Fear/anxiety about one+ social situation, in which the individual is exposed to possible scrutiny by others (in children, fear must be present with peers, not only adults)
2. Individual fears that they will act in a way/show anxiety symptoms that will be negatively evaluated
3. Social situations almost always provokes fear/anxiety (in children crying, tantrums, freezing, clinging, shrinking or not talking)
4. Social situations are avoided or endured with intense fear/anxiety
5. Out of proportion to the threat posed and to the sociocultural context
6. Fear/anxiety/avoidance is persistent, typically **6+ months**
49
Symptoms panic disorder?
Recurrent and unexpected panic attacks, **4+** symptoms need to occur (can occur from calm or anxious state)
1. Palpitations, pounding heart or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11. Derealization or depersonalization
12. Fear of losing control or "going crazy"
13. Fear of dying
At least one of the attacks has been followed by **1+ month** of either/both
1. Persistent concern or worry about additional panic attacks or their consequences
2. A significant maladaptive change in behaviour related to the attacks (e.g., behaviour to avoid attacks)
50
How does the DSM define a panic attack?
An abrupt surge of intense fear or intense discomfort that reaches a peak wihin minutes
51
Criteria of panic attack specifier, with what other disorders can this be given?
Can be given with any other DSM disorder
Criteria same as A. for panic disorder, to reiterate: **4+**
1. Palpitations, pounding heart or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11. Derealization or depersonalization
12. Fear of losing control or "going crazy"
13. Fear of dying
52
Symptoms agoraphobia?
Fear/anxiety about **2+** situations
1. Using public transportation
2. Being in open spaces
3. Being in enclosed spaces
4. Standing in line/being in a crowd
5. Being outside of the home alone
Individual fears/avoids because of thoughts that escape might be difficult or help might not be available in the event of panic-like symptoms or other incapacitating/embarrassing symptoms
Must provoke anxiety/fear almost always
Actively avoided, require companion or are endured with intense fear or anxiety
Out of proportion
persistent, **6+ months** typically
53
Symptoms GAD?
Excessive anxiety and worry, **6+ months**, about a number of events or activities
Difficulty to control worry
Associated with **3+** of the following
1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance
54
OCD symptoms?
1. Presence of obsessions and/or compulsions
2. Obsessions/compulsions are time consuming or cause clinical distress or impairment social/occupational/etc.
55
How are obsessions and compulsions defined in OCD?
Obsessions:
1. Recurrent and persistent thoughts, urges or images that are intrusive and unwanted (generally causes anxiety or distress)
2. Attempts to ignore/suppress and/or neutralize them with some other thought/action (i.e., compulsions performed)
Compulsions:
1. Repetitive behaviours or mental acts that individual feels drived to perform in response to an obsession or according to rules that must be applied rigidly
2. Above are aimed at preventing/reducing anxiety/distress/dreaded event; however, are not actually connected in a realistic way to said thing or are excessive
56
OCD HiTOP?
Internalizing, with subfactor fear
57
PTSD symptoms?
| for >6 years of age
**Exposure** to actual or threatened death, serious injury or sexual violence in **1+** of the following ways
1. Direct experience
2. Witnessing, in person, the events in others
3. Learned that events occured to close family/friend
4. Experiencing repeated or extreme exposure to details of event (e.g., first responders) - this does not account for digital exposure, unless in the wake of work-related
**Intrusion symptoms**, **1+**
**Persistent avoidance of associated stimuli**, after event, **1+**
**Negative alterations in cognitions/moods**, **2+**
**Negative alterations in arousal, 2+**
Duration of above **1+ month**
| criteria groups need to be known, details of not really
58
Acute stress disorder symptoms?
Exposure = same criteria as PTSD
Presence of **9+** from the five categories (**Intrusion, negative mood, dissociative symptoms, avoidance symptoms and arousal symptoms**)
3days-1month in duration
59
PTSD HiTOP?
Internalizing, subfactor distress
60
Symptoms adjustment disorder?
1. The development of emotional or behavioural symptoms in response to an identifiable stressor(s) occuring within **3 months** of the onset of the stressor
2. These symptoms/behaviours are clinically significant as evidenced by either masked distress (out of proportion) and/or significant impairment in important areas of functioning
3. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a pre-existing mental disorder
61
DID symptoms?
1. **Disruption of identity characterized by 2+ distinct personality states** (may be described as an experience or possession, depending on culture). Disruption marks **discontinuity in sense of self and sense of agency**. This is **accompanied by related alterations in affect, behaviour, consciousness, memory, perception, cognition and/or sensory-motor functioning.**
2. Recurrent gaps in the recall of everyday events, important personal information and/or traumatic events that are inconsistent with ordinary forgetting
62
Dissociative amnesia symptoms?
An inability to recall important autobiographical information, usually of a traumatic of stressful nature, that is inconsistent with ordinary forgetting
note: generally localized or selective amnesia for specific event(s) or generalized for identity and life history
63
Depersonalization/Derealization disorder symptoms?
1. The presence of persistent or recurrent experiences of depersonalization, derealization or both
2. During the depersonalization or derealization experiences, reality testing remains intact
64
How is depersonalization and derealization defined in the DSM
Depersonalization: Experiences of unreality, detachment or being an outside observer with respect to one's thoughts, feelings, sensations, body or actions
Derealization: Experiences of unreality or detachment with respect to surroundings
65
Somatic symptom disorder symptoms?
**1+** somatic symptoms that are distressing or result in significant disruption or daily life
Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by **1+** of following:
1. Disproportionate and persistent thoughts about the seriousness of one's symptoms
2. Persistently high level of anxiety about health or symptoms
3. Excessive time and energy devoted to these symptoms or health concerns
66
Somatic symptom disorder HiTOP?
Somatoform (surprising)
67
Illness anxiety disorder?
1. Preoccupation with having or acquiring a serious ilness
2. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition, the preoccupation is excessive/disproportionate
3. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status
4. The individual performs excessive health-related behaviours or exhibits maladaptive avoidance
68
Illness anxiety disorder HiTOP?
Somatoform
69
Coversion disorder (functional neurological symptom disorder) symptoms?
1. **1+** symptoms of altered voluntary motor or sensory function (aka they are fucked somehow, e.g., paralysis)
2. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions
70
Anorexia nervosa symptoms?
1. Restriction of energy intake relative to requirements, leading to a significantly low body weight (context-related). Significantly low weight is < minimally normal or expected
2. Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain (even though already at significantly low weight)
3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight
71
Anorexia Nervosa HiTOP?
Internalizing, subfactor eating
72
Bulimia Nervosa symptoms?
Recurrent episodes of binge eating, characterized by **both** of the below:
1. Eating, in a discrete period of time (e.g., an hour), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances
2. A sense of lack of control over eating during the epiosde
Recurrent inappropriate compensatory behaviours in order to prevent weight gain
The binge eating and inappropriate compensatory behaviours both occur, on average, **at least once a week for 3 months**
Self-evaluation is unduly influenced by body shape and weight
73
Bulimia Nervosa HiTOP?
Internalizing, subfactor eating
74
Oppositional Defiant Disorder symptoms?
A pattern of below categories lasting **6+ months,** with **4+ symptoms** below and **1+ interaction with a non-sibling**
Angry/irritable mood:
1. Often loses temper
2. Is often touchy or easily annoyed
3. Is often angry and resentful
Argumentative/defiant behaviour:
1. Often argues with authority or adults if children/adolescents
2. Often actively defies or refuses to comply with requests from authority figures or rules
3. Often deliberately annoys others
4. Often blames others for his or her mistakes or misbehaviour
Vindictiveness:
1. Has been spiteful or vindictive **at least twice within the past 6 months**
75
Oppositional Defiant Disorder HiTOP?
Disinhibited and antisocial externalizing, subfactor antisocial behaviour
76
Conduct disorder symptoms?
Repetitive and persistent pattern of behaviour in which the basic rights of others/societal norms are violated, **3+ symptoms in the past 12 months (at least one in the past 6 months)**
Aggression people and animals:
1. Bullies, threatens or intimidates others
2. Initiates physical fights
3. Used a weapon that can cause serious physical harm to others
4. Has been physically cruel to people and/or animals
5. Has stolen while confronting a victim (e.g., mugging)
6. Has forced someone into sexual activity
Destruction of property:
1. Deliberate fire setting with intention of serious damage
2. Deliberate destruction of property (other than fire)
Deceitfulness/theft:
1. Has broken into property
2. Lies to obtain smth or avoid obligations
3. Stealing of nontrivial items without confrontation (e.g., shoplifting)
Violations of rules:
1. <13 start, often staying out at night, despite prohibitions
2. Run a way from home overnight, at least twice (whilst living in parental home) or once for a lengthy period
3. Skipping school, <13
| oof
77
Three categories in oppositional defiant disorder?
Angry/irritable mood, argumentative/defiant behaviour and vindictive behaviour
78
Four categories in conduct disorder?
Aggression to people and animals, destruction of property, deceitfulness or theft and serious violation of rules
79
Conduct disorder HiTOP?
Disinhibited & antagonistic externalizing, subfactor antisocial behaviour
80
What are frequency indications in children < 5 years and individuals > 5 years for oppositional defiant disorder?
< 5 years = behaviour present for most days, 6+ months
> 5 years = once a week, 6+ months (except for vindictiveness)
81
Substance use disorder HiTOP?
Disinhibited externalizing, subfactor substance use (lol)
82
Substance use disorder symptoms? (this uses the one for alcohol, they are all similar)
A problematic pattern of substance abuse leading to clinically significant impairment or distress, **2+ symptoms, within 12-month period**
1. Substance is often taken in larger amounts or over a longer period than intended
2. Persistent desire or unsuccessful efforts to cut down/control substance use
3. Significant amount of time spent in activities necessary to obtain/use substance or recover from its effects
4. Craving or strong desire for substance
5. Recurrent substance use, resulting in failure to fulfill major role obligations
6. Continued substance use despite persistent/recurrent interpersonal problems caused by substance
7. Important activities are given up/reduced because of substance use
8. Recurrent substance use in dangerous situations (driving a car, perhaps?)
9. Substance use continued despite knowledge of physical/psychological problem likely caused/exacerbated by substance
10. Tolerance either; need for markedly increased amounts to achieve desired effects or markedly diminshed effect with the same amount
11. Withdrawal either: characteristic substance withdrawal or substance taken to relieve withdrawal symptoms
| good luck with this one
