Recall Set 2 (2023)

Question 1

Question
1. Anxiety
? Selective mutism
what are 3 negative prognostic factors

Answer 1

o psychiatric comorbidity (ex. ASD, MDD)
o medical comorbidity (ex. Epilepsy)
o low IQ
o low SES
o family history
o neuroticism
o shyness
o social isolation

Question 2

anxiety/SM

• What are 2 developmental delays/disorders that they are at risk for?

Answer 2

o receptive language disorder
o social communication disorder
o specific learning disorder
o childhood onset fluency disorder

Question 3

Really unwell teen girl. Seizing a lot in ER. History of epilepsy but this is different. Orofacial movements.
* Most likely medical thing?

Answer 3

o NMS
o EPS
o serotonin syndrome
o epilepsy
o infectious cause
o encephalitis
o substance induced
o TBI/stroke

Question 4

Really unwell teen girl. Seizing a lot in ER. History of epilepsy but this is different. Orofacial movements.

• If she had taken a lot of risperidone, what would this be

Answer 4

o NMS/EPS/Serotonin syndrome related

Question 5

• What are 3 neuromuscular signs/symptoms of serotonin syndrome

Answer 5

o myoclonus/clonus–spontaneous or inducible
o ocular clonus
o hyper-reflexia
o agitation
o tremor

Question 6

National Aboriginal Youth Suicide Prevention Strategy – official government document
* What can be done at a primary prevention level

Answer 6

o –increased number of trained gatekeeper in communities (i.e natural helpers, police, social service providers etc)
o –increased networks/social connections by youth
o –increase number of regional/community partnerships in place
o –increased suicide prevention training by local professionals and community members
o –available and accessible information tools, and resources on suicide
o –increased support amongst peers/development of supportive networks

Question 7

DMDD:
* If someone meets criteria for bipolar disorder and DMDD, which do you diagnose

Answer 7

bipolar trumps DMDD

Question 8

• If someone meets criteria for ODD and DMDD, which do you diagnose
• If someone meets criteria for IED and DMDD, which do you diagnose

Answer 8

DMDD trumps ODD and IED

Question 9

Depression
* What do you assess/do in safety planning for SI. 5 things.

Answer 9

o previous attempts
o current SI
o intent, plan
o lethality, access, reasonableness of plan
o access to guns, substances/meds
o what are their supports?
o safety proofing home, planning
o timely follow up
o assess insight and judgment
o psychiatric diagnoses/comorbidities

Question 10

Depression
* Kid on fluoxetine and CBT. Still has severe depression. What do you do next as per guidelines? What do you do after that?

Answer 10

o optimize med
o –change to another first line SSRI/med
o –trial third line agent like venlafaxine or TCA
o –consider with of therapy to IPT
o –consider ECT/rTMA “with significant caution”
o –augment with another agent
o –reassess diagnosis
o –cite TORDIA study, CANMAT special populations

Question 11

Disruptive
* Name 5 principles of multisystemic therapy

Answer 11

o –finding the fit (identifying the problems and how they make sense in the context of the persons environment)
o –focusing on positives and strengths (family strengths as well–builds hope, IDs protective factors and decreases frustration)
o –increasing responsibility (promote responsible behavior by family members)
o –present focused, action oriented, and wellbeing defined (dealing with the here and now of a young persons life; tracks progress of treatment; provides clear criteria of success)
o –targeting sequences (what is sustaining the problems)
o –developmentally appropriate (emphasizes the person getting along well with peers, academic and vocational skills)
o –continuous effort (daily or weekly)
o –evaluation and accountability (no labeling of families as resistant, not ready for change, unmotivated–keeps team members accountable for finding ways to get over barriers)
o –generalization (to invest the parents or carers in the ability to address family needs after the intervention is over)

Question 12

Eating
* Admission criteria for ED pt

Answer 12

o –severe malnutrition (<75% IBW)
o –Medical issues–Dehydration, Electrolyte abnormalities (low K, low Mg, low Phos), Acute complications e.g.pancreatitis, Cardiac dysrhythmias
o –Physiological instability–Bradycardia (<50 bpm daytime, <45bpm overnight), Hypotension (orthostasis or <90mmHG systolic), Hypothermia (<35.5), Orthostatic changes
o –Acute food refusal
o –Arrested growth and development
o –Uncontrollable binging/purging
o –Acute psychiatric emergencies e.g.suicidal attempt
o –Treatment for comorbid condition interfering with ED treatment
o –Failure of outpatient treatment

Question 13

• ECT – psychotic youth who has failed medical management with catatonia. 5 arguments you would make to tell the family and the patient that it is safe. (not explaining how ECT works)

Answer 13

o –in BC, a second physician assessed for ECT appropriateness/indication/safety
o –two physicians are present for the treatment–psychiatrist and anesthesiologist plus nursing staff
o –we use a muscle relaxant/paralytic
o –general sedation monitored by anesthesia
o –performed in a monitored/surgical setting
o –mortality of anesthesia is higher than the mortality of ECT itself
o –80-90% effective in mood disorder–> getting ECT for a severe mood disorder/catatonia is likely safer than an untreated disorder
o –greatest risks: memory loss, status (which can be aborted with anti seizure meds)
o –most common Session: headache, muscle soreness, nausea, jaw pain
o –safer than suicide
o –use a short acting anesthestic agent
o –use lowest effective stimulus
o –closely monitored afterwards
o –life saving treatment

Question 14

Elimination—Encopresis
* What % have constipation

Answer 14

o up to 80-90%

Question 15

• 3 components treatment of encopresis

Answer 15

o –psychoeducation about encopresis
o –Bowel cleansing: Disimpaction, Stool softener
o –Bowel training: Behavior modification
o Sit on the toilet for 10 minutes after meals
o Gastrocolic reflex
o Create habit of using the toilet
o Foot stool (Valsalva ↑ abdominal pressure)
o Rewards
o –encouraging healthy bowel movements i.e dietary changes
o –Parents must understand there is no quick fix, relapses are common
o –Adding biofeedback questionable benefit

Question 16

• Most likely psych comorbidity with encopresis

Answer 16

o –eneuresis
o –most likely medical is UTIs

Question 17

Neurodev
* What academic psychological tests can be done on a 6 year old (3)

Answer 17

o California Verbal Learning Test
o Wide Range Assessment of Learning and Memory
o Stanford Binet Intelligence Scale (2+)
o Kauffman Assessment Battery for Children (2-12)

o **WIAT (Weschler individual Achievement Test) (4-19)
o **WISC (Weschler Intelligence Scale for Children) (6-16)
o **Weschler Preschool Primary Scale of Intelligence (2-7)

Question 18

• What are 3 adaptive functioning domains

Answer 18

o –social
o –conceptual
o –practical
 *rank severity based on adaptive functioning
 “IQ tests are lousy when you get to the lower end of the scale, and also they are not culturally and linguistically validated”

Question 19

Neurodev
? LD in reading.
* What to look for on developmental history (3)

Answer 19

o –language and fine motor delays
o –lower school achievement, avoidance of School, school related behavior problems
o –prematurity, very low birth weight
o –prenatal nicotine
o –family history of reading or math disabilities

Question 20

• What are two building blocks in the skill of reading

Answer 20

o –phoenemic awareness (ability to identify and manipulate individual sounds)
o –phonics (process of systematically mapping the phonemes onto graphemes)
o –vocabulary
o –fluency
o –comprehension

Question 21

Neurodev-ADHD
4 yo with ADHD
* Non med treatment

Answer 21

o –parent management training
o –psychoeducation
o –school support
o –behavioural approaches
o –skills based programs (social)
o –anger manegemtn and time management
o –relaxation techniques, mindfulness
o –family therapy to prevent scapegoating of the child
o –couples/marital therapy

Question 22

• Stimulant side effects in 4 year old vs school age (2)

Answer 22

o Preschool children experience higher rates of side effects, especially irritability and moodiness, and, typically, better tolerate smaller doses of stimulant medications [55].
o ?greater impact on sleep and appetite
o ?more likely to reach 12 year threshold for difference in height?
o MORE LIKELY to have side effects like irritability, appetite suppression, activation, headache
o IRRITABILITY and moodiness specifically are likely to be worse in a younger child than an older child according to the Canadian Pediatric Society

Question 23

• Effects of methylphenidate on 4 year old vs school age

Answer 23

o –there is not HC/FDA approval for mono therapy for stimulants under age 6 due to lack of data for efficacy and safety in this age group
o –8/9 studies supported efficacy of treatment of preschoolers with methylphenidate (AACAP paper) at a dose that is similar and comparable with respect for mg/kg that is used in school age children
o –those with significant developmental delays in preschoolers had more side effects like social withdrawal, irritability and crying
o –preschool group showed higher rate of emotional adverse events, crabiness, irritability, proneness to crying
o –MPH/any stimulant should be titrated more conservatively compared to school age patients and lower doses may be effective
o –preschoolers metabolized MPH MORE SLOWLY compared to school aged children

Question 24

bonus Q: why is it important to treat ADHD with stimulants if indicated

Answer 24

Outcomes from well-designed, long-term trials to evaluate the effectiveness of stimulants for ADHD are under-researched [16] and, due to publication bias [17], may also be under-reported. Stimulants appear to improve parent-reported quality of life in children being treated for ADHD [18]–[21] and are associated with improved academic achievement and lower rates of comorbid anxiety and depression in young adulthood [22]. However, lasting impact on the core symptoms of ADHD has not been confirmed [23].

Short-term randomized control trials of stimulant use for ADHD have shown that these medications can improve function in multiple domains, including decision-making [21], handwriting [24], and school work productivity [25]. Among adolescents and young adults with ADHD, longer-acting preparations of extended-release (ER) stimulants have demonstrated improved evening driving performance [26]. Population-based observational studies have indicated that stimulant treatment is also associated with better math and reading scores [27], fewer injuries leading to emergency room visits [28][29] and reduced morbidity and mortality related to motor vehicle injuries [30].

Long-term cohort studies following children who were diagnosed in childhood with ADHD into adulthood, compared with children living without ADHD, have documented that individuals with ADHD who continue to experience higher rates of inattention, impulsiveness and hyperactivity than their typical peers will also have greater difficulties with educational and occupational adjustments, risky sexual behaviours, and psychiatric disorders than those for whom core ADHD symptoms diminished over time [31][32].

These studies suggest that when ADHD symptoms persist into young adulthood, there is reason to continue stimulant treatment to address them. Indeed population studies show that stimulant use is associated with better employment outcomes [31][32], and reduced morbidity and mortality related to motor vehicle injuries [30].

Question 25

Neurodev-ADHD
* What would lead to you lean towards a drug holiday in youth on stimulants (5 things)

Answer 25

o –impacts on sleep
o –appetite suppression
o –family or patient preference
o –family concerns of long term drug effects
o –cost of med
o –determination of adverse effects ?due to med –is the drug working well?
o –diagnostic clarification i.e anxiety
o –concerns around growth
o –improve drug effectiveness
o –do you need to stay on the med?

Question 26

Neurodev-ADHD
ADHD
* 5 things long term outcomes in teens/adults if you don’t treat ADHD

Answer 26

o –more likely to have a car accident
o –more likely to have SUD
o –lower educational and vocation achievement
o –shittier relationships
o –more likely to develop anxiety/depression/other psych comorbidity
o –higher risk of ODD/conduct etc
o –higher risk of suicide
o –fewer injuries leading to ER visits
o –less behaviors related to impulsivity i.e sexual
o –financial

Question 27

Neurodev-ASD
* Medical conditions that could cause an ASD presentation

Answer 27

o –Rett Syndrome
o –PKU
o –Fragile X
o –DiGeorge
o –FASD
o –Tuberous Sclerosis
o –NF
o –Kleinfelter syndrome

Question 28

Neurodev-ASD
* Risk factors that are the same between ASD and psychosis (3)

Answer 28

o –increased parental age
o –chromosomal abnormalities/genetics i.e 22q11 deletion syndrome
o –family history
o –prematurity/low birth weight/pregnancy and birth complications
o –prenatal exposures i.e pesticides, valproate, infections

Question 29

• Two symptoms that are consistent between ASD and psychosis

Answer 29

o –social withdrawal (prodrome vs social deficits)
o –limited affect
o –alogia
o –adaptive deficits
o –concrete thinking

Question 30

Neurodev-ASD
* FASD two facial features

Answer 30

o –smooth philtrum
o –shortened palpebral fissures
o –thin upper lip

Question 31

OCD
* OCD vs OCPD

Answer 31

o –ego dystonic vs ego syntonic
o –obsessions/compulsions vs focus on rigidity/rule following/perfectionism in OCPD
 repetitive behaviors
o –response to SSRIs
o –OCD more likely to be functionally impairing
o OCPD is not characterized by intrusive thoughts/images or compulsions/repetitive behaviors associated with OCD. Instead, it is associated with a pervasive pattern of excessive perfectionism and rigid control.
o Can have both.

Question 32

. OCD
* OCD brain abnormalities

Answer 32

o Abnormalities in the CSTC loop implicated in OCD
o Caudate may be smaller but that means the brakes are smaller when it comes to paying attention to extraneous info.
o Also systems are in overdrive so getting more information through a less inhibited system.

“Many investigators have contributed to the hypothesis that OCD involves dysfunction in a neuronal loop running from the orbital frontal cortex to the cingulate gyrus, striatum (cuadate nucleus and putamen), globus pallidus, thalamus and back to the frontal cortex.”

while the overall patterns are quite similar, a few brain regions markedly more active in the OCD brain. The two most prominent are the orbitofrontal cortex (OFC), at the front of the brain just above the eyeballs, and the caudate nucleus, a component of the basal ganglia deep within the brain. Remember those terms - we’re going to come back to them.

It’s like a positive feedback loop. And, somehow, this loop is in overdrive in OCD. At least, that’s how it looks from the neuroimaging data.

A few decades of subsequent work have refined but largely supported this picture. Additional areas of hyperactivity have been identified, such as the anterior cingulate cortex (ACC), the anterior thalamus, and, in some studies, the insula.

The problem is, even when we are pretty sure there are differences between brain activity in folks with OCD and those without, on average, that doesn’t necessarily help us make predictions about a given individual. It’s kind of like the relationship of height to sex. On average, men are taller than women. But if I just tell you someone’s height, you’re not going to be very accurate in guessing their sex. And if I tell you whether someone is male or female, you’re not going to be able to guess their height with any great precision. There is an indubitable relationship between height and sex, on average, but it doesn’t do you a whole lot of good in an individual case.

Question 33

Other
* What is the primary function of NSSI?

Answer 33

o It is now well established that affect regulation—using NSI to alleviate intense negative emotions—is the most common function of NSI, endorsed by more than 90 % of those who engage in the behavior [4, 15, 14].
o “Alleviate overwhelming negative emotion”

Question 34

• What are other functions of NSSI other than affect regulation?

Answer 34

o It is also well documented that 50 % or more of those who self-injure endorse self-punishment, or self-directed anger, as a motivation for NSI [14], a pattern that has led subsequent studies to elucidate the role of self-criticism in NSI [12].
o “Self punishment”
o Many other NSI functions have also been identified including anti-dissociation (e.g., causing pain to stop feeling numb), anti-suicide (e.g., stopping suicidal thoughts), peer bonding (e.g., fitting in with others), interpersonal influence (e.g., letting others know the extent of emotional pain), and sensation seeking (e.g., doing something to generate excitement) [14, 17].
o “Desire to influence others, produce physical sign of distress”

Question 35

Pharmacology
* Which two meds have multiple placebo RCTs supporting their use in mania

Answer 35

o Lithium
o Risperidone

Question 36

Pharmacology
* Li- predictors of good and poor response.

Answer 36

o Good response:
 –positive family history of bipolar disorder
 –family history of good response to lithium
 –previous good response
 –classical euphoric mania presentation
 –absence of comorbid personality disorders
 –bipolar type I
 –early onset of lithium treatment
 –melancholic features during depressive episodes
 –episodic remitting
 –low rates of comorbidity
 –pattern of mania-depression-euthymia in biphasic pattern
 –lack of EEG abnormalities

o Poor response:
 –early onset of bipolar disorder before age 18
 –higher number of previous affective episodes before lithium initiation
 –previous poor response
 –irritable/MIXED EPISODES/dysphoric mania
 –rapid cycling
 –comorbid alcohol and drug abuse
 –mood disorder with INCONGRUENT psychotic features

Question 37

• Pharmcokinetics of li in kids compared to adolescents.

Answer 37

o The lithium PK properties in young children were similar to those in older children and adults.

o Findling et al. (3) found that when specifically tested in the pediatric population (average age: 11.8 years), the average half-life was 17.9 hours, and the investigators concluded that children have a shorter elimination half-life and greater clearance compared with adults due to the fact that clearance is correlated with total body weight and fat-free mass.

Question 38

Psychotherapy
Vinette on youth with depression.
* What are 5 foci/areas of focus in this youth in IPT

Answer 38

• What are 5 foci/areas of focus in this youth in IPT
  o –assignment of the sick role
  o –creating the interpersonal inventory
  o –choose a focus of therapy/which interpersonal problem area you will focus on (i.e grief, interpersonal sensitivities/deficits, role dispute, role transition)
   GRID (grief, role transition, interpersonal deficits, role Disputes)
  o –perform communication analysis
  o –exploration of options and decision analysis
  o –establish number of sessions (time limited therapy), structured treatment with beg, middle, end
  o –termination

Question 39

Psychotherapy
* 4 factors in group therapy

Answer 39

o –universality
o –installation of hope
o –imparting information
o –altruism
o –corrective re-capitulation of primary family experience
o –development of socializing techniques
o –imitative behavior
o –interpersonal learning including input and output
o –cohesiveness
o –catharsis
o –existential factors
o –self understanding

Question 40

• One diagnosis not to have in group therapy

Answer 40

ASPD

Question 41

Substance
* 5 features of cannabis withdrawal

Answer 41

o –anxiety
o –sleep disturbance
o –headache
o –nausea/vomiting
o –poor appetite
o –irritability, anger
o –restlessness
o –depressed mood
o –abdo pain
o –shakiness/tremors
o –sweating
o –fever, chills

Question 42

Schizophrenia
* Differentiate mania vs psychosis?

Answer 42

o –mania–> reduced need for sleep which you wouldn’t have with SCZ
o –SCZA you need two weeks of primarily psychotic symptoms WITHOUT mood sx
o –temporal relationship between mood sx and psychotic symptoms if its bipolar and not SCZ

Question 43

Schizophrenia
* Bipolar and ADHD: differentiate

Answer 43

o –ADHD is longitudinal vs bipolar is episodic
o –ADHD not associated with euphoric, elevated mood or psychosis
o –both have impulsivity and emotion regulation difficulties

o ADHD distinct characteristics:
 Initial insomnia/sleep disorders
 Chronic restlessness
 Impulsive sexual encounters
 Chronic course
 Chronic distractibility and/or impulsivity
 Bipolar distinct characteristics:
 Decreased need for sleep
 Episodes of speediness/increased rate of speech
 Hyper sexuality
 Episodic course
 Episodic related distractibility
 Feeling “high” or euphoric mood
 Grandiosity

o Conditions that Can Mimic ADHD Symptoms or Signs not Characteristic of ADHD
o Bipolar Disorder I or II (manic or hypomanic episode) Episodic change from baseline; psychotic symptoms; grandiosity; pressured speech; recent decreased need for sleep.

Question 44

Schizophrenia
Childhood schizophrenia:
* Name 3 cognitive deficits in children with schizophrenia

Answer 44

o In early onset schizophrenia, studies have found large deficits in general intellectual ability, processing speed, working memory, verbal memory and learning; medium deficits in rule discovery and perseveration, planning and problem solving; and minimal deficits in attention

o WORKING MEMORY!!!
o EXECUTIVE FUNTION
o ?attention
o GLOBAL IMPAIRMENTS

o Premorbid problems with verbal reasoning, working memory, attention and processing speed

Question 45

Sleep
* 5 things that come with sleep deprivation

Answer 45

o –ADHD like symptoms (inattention, distractibility, impulsivity)
o –impacts on brain development
o –learning problems
o –more negative emotions
o –impaired working memory
o –impaired decision making
o –delayed reaction time

o -daytime sleepiness
o -fatigue
o -impaired judgment

According to a study, children with reduced sleep are more likely to struggle with verbal creativity, problem solving, inhibiting their behaviour

Question 46

Suicidality
* Why is it important to diagnose BPD in teens?

Answer 46

o –so they can get treatment and reduce risk of SI/SA
o –prognostically helpful
o –importance of early intervention
o –personality is still malleable

Question 47

Therapy
* DBT four modules to help emotion regulation

Answer 47

o DBT four modules are:
 Mindfulness
 distress tolerance
 emotion regulation
 interpersonal effectiveness
o Within emotion regulation, goals are:
 naming and understanding our own emotions
 decrease the frequency of unpleasant emotions
 decrease our vulnerability to emotions
 decrease emotional suffering.
o Emotion regulation skills taught in DBT include:
 STOP (Stop, Take a step back, Observe, Proceed mindfully)
 Opposite action to emotion
 ABC Please (The ABC PLEASE skill is about taking good care of ourselves so that we can take care of others. Also, an important component of DBT is to reduce our vulnerability. When we take good care of ourselves, we are less likely to be vulnerable to disease and emotional crisis)
 Building Mastery
 Cope Ahead
 Positive Self Talk

Question 48

• Family component of DBT

Answer 48

o Family Skills Training?
o The complementary family interventions proposed in this article aim to: 1) provide all family members an understanding of borderline behavioral patterns in a clear, nonjudgmental way; 2) enhance the contributions of all family members to a mutually validating environment; and 3) address all family members’ emotion regulation and interpersonal skills deficits.

o All the same modules except mindfulness? NOT SURE

o Then, two core assessment procedures are explored, with clinical examples: (a) conducting “double chain” analyses, demonstrating how one person’s social or relationship responses affect the other’s emotional arousal (and vice versa); and (b) direct behavior observation of family interactions, which allow treatment targets to be identified efficiently. These two assessment strategies may also be combined.

o Three main categories:
 Decrease the risk off psychopathology in the future–> life threatening behaviors, therapy destroying behaviors of a child, therapy interfering behaviors of a parent, parental emotional regulation, effective parenting techniques
 Target parent child relationship–> improve parent child relationship
 target child’s presenting problems–> address risky/unsafe/aggressive behaviors, address quality of life interfering problems, skills training, therapy interfering behaviors of the child
`

Question 49

Trauma
? RAD description
* 2 differential?

Answer 49

o –ASD
o –depression
o –ID/GDD
o –language delays/disorders
o –PTSD

Question 50

• Strange situation experiment, how would RAD kid respond

Answer 50

o –unlikely to react with caregiver leaves
o –do not seek comfort from others when distressed (unlikely to seek comfort from caregiver on return)
o –may show unexplained irritability/sadness/fearfulness at other times during the experiment
o –may react violently when held, cuddled, or comforted
o –affected children are unpredictable, difficult to console
o –Moods fluctuate erratically, and children may seem to live in a fight, flight, or freeze mode.

o Further, we found that the young children who had more signs of reactive attachment disorder showed fewer signs of attachment behavior in the Strange Situation

Question 51

Trauma in 5 year old, comparing child vs adult ptsd what is unique (5 things)

Answer 51

• PTSD for Children 6 Years and Younger:

o 1+ Intrusion Sx
 –intrusive memories may be repetitive play (unlike in adults)
 –nightmares or frightening dreams WITHOUT recognizable content (in adults, it must be recognizable content)
 –kids may not have flashbacks–>may have trauma specific re-enactment instead
o 1+ avoidance OR negative emotions or cognitions
 –symptoms of avoidance are the same between adults and kids
 –synptoms of negative emotions/cognitions are different between adults and kids (in kids, it is increased negative emotional states–in adults this is “persistent”; anhedonia –SAME; socially withdrawn behavior; reductions in expression of positive emotions–in adults this is “persistent”)
o 2+ arousal/reactivity sx
 –kids do not have “reckless or self destructive behavior”

o What is unique? The criteria are slightly different–> need more alterations in negative mood and cognitions in adults
 Kids may have repetitive play instead of clearly intrusive memories
 kids may have frightening dreams WITHOUT recognizable content
 kids may have trauma specific re-enactment instead of flashbacks
 kids do not need persistent negative mood or inability to feel positive emotions–just need more frequent negative emotional states or reduction in expression of positive emotion
 kids do not have a criteria for reckless or self destructive behavior, nor is there criteria for “negative beliefs about self/other/world”
 Kids may also have developmental regression which supports diagnosis.
 In kids, trauma can occur to the parent/caregiver and not just to the child.

o Children may become more preoccupied with reminders of the trauma. Because of limitations in expressing thoughts/emotions, the negative alterations/cognitions tend to involve primarily mood changes. Avoidant behavior can encompass restricted play or restricted exploratory behavior, reduced participation in new activities in school aged children or reluctance to pursue developmental opportunities in adolescence.

o For Adults:

 1+ intrusion
 1+ avoidance
 2+ negative alternations in cognitions/mood
 2+ arousal