Mnemonics in a Mnutshell_ 32 Aids to Psychiatric Diagnosis _ Current Psychiatry

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Mnemonics in a mnutshell: 32 aids to psychiatric diagnosis

Jason P. Caplan, MD, Theodore A. Stern, MD

October 1, 2008

Clever, irreverent, or amusing, a mnemonic you remember is a lifelong learning tool

Vol. 7, No. 10 / October 2008

ason P. Caplan, MDssistant clinical professor of psychiatry, Creighton University School of Medicine, Omaha, NE, Chief of psychiatry

Josephs Hospital and Medical Center Phoenix, AZ

Theodore A. Stern, MD

rofessor of psychiatry, Harvard Medical School Chief, psychiatric consultation service, Massachusetts General

Hospital, Boston, MA

rom SIG: E CAPS to CAGE and WWHHHHIMPS, mnemonics help practitioners and trainees recall important listsuch as criteria for depression, screening questions for alcoholism, or life-threatening causes of delirium, respectiv

Mnemonics efficacy rests on the principle that grouped information is easier to remember than individual points ofdata.

Not everyone loves mnemonics, but recollecting diagnostic criteria is useful in clinical practice and research, on boaexaminations, and for insurance reimbursement. Thus, tools that assist in recalling diagnostic criteria have a role inpsychiatric practice and teaching.

n this article, we present 32 mnemonics to help clinicians diagnose:

affective disorders (Box 1)1,2

anxiety disorders (Box 2)3-6

medication adverse effects (Box 3)7,8

personality disorders (Box 4

)

9-11

addiction disorders (Box 5)12,13

causes of delirium (Box 6).14

We also discuss how mnemonics improve ones memory, based on the principles of learning theory.

How mnemonics work

A mnemonicfrom the Greek word mnemonikos (of memory)links new data with previously learnednformation. Mnemonics assist in learning by reducing the amount of information (cognitive load) that needs to b

tored for long-term processing and retrieval.15


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Memory, defined as the persistence of learning in a state that can be revealed at a later time,16can be divided into ypes:

declarative (a conscious recollection of facts, such as remembering a relatives birthday)procedural (skills-based learning, such as riding a bicycle).

Declarative memory has a conscious component and may be mediated by the medial temporal lobe and corticalassociation structures. Procedural memory has less of a conscious component; it may involve the basal ganglia,

cerebellum, and a variety of cortical sensory-perceptive regions.17

OX 1.

MNEMONICS FOR DIAGNOSING AFFECTIVE DISORDERS

Depression

SIG: E CAPS*Suicidal thoughtsInterests decreasedGuiltEnergy decreasedConcentration decreasedAppetite disturbance (increased ordecreased)Psychomotor changes (agitation orretardation)Sleep disturbance (increased or

decreased)* Created by Carey Gross, MD

Dysthymia

HES 2 SAD2HopelessnessEnergy loss or fatigueSelf-esteem is low2years minimum of depressed mood most of the day, formore days than notSleep is increased or decreasedAppetite is increased or decreasedDecision-making or concentration is impaired

ManiaDIG FASTDistractibilityIndiscretionGrandiosityFlight of ideasActivity increaseSleep deficitTalkativeness

Depression

C GASP DIE1Concentration decreasedGuiltAppetiteSleep disturbancePsychomotor agitation or

retardationDeath or suicide (thoughts or actsof)Interests decreasedEnergy decreased

HypomaniaTAD HIGHTalkativeAttention deficitDecreased need for sleepHigh self-esteem/grandiosityIdeas that raceGoal-directed activity increasedHigh-risk activity

ManiaDeTeR the HIGH*DistractibilityTalkativenessReckless behaviorHyposomniaIdeas that raceGrandiosityHypersexuality* Created by CareyGross, MD

Declarative memorycan be subdivided into working memory and long-term memory.

With working memory,new items of information are held briefly so that encoding and eventual storage can take pl


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Working memory guides decision-making and future planning and is intricately related to attention.18-21FunctionalMRI and positron emission tomography as well as neurocognitive testing have shown that working memory tasksactivate the prefrontal cortex and brain regions specific to language and visuospatial memory.

he hippocampus is thought to rapidly absorb new information, and this data is consolidated and permanently stored

he prefrontal cortex.22-26Given the hippocampus limited storage capacity, new information (such as what you ate

breakfast 3 weeks ago) will disappear if it is not repeated regularly.17

Long-term memory,on the other hand, is encoded knowledge that is linked to facts learned in the past; it isconsolidated in the brain and can be readily retrieved. Neuroimaging studies have demonstrated opposing patterns oactivation in the hippocampus and prefrontal cortex, depending on whether the memory being recalled is:

new (high hippocampal activity, low prefrontal cortex activity)

old (low hippocampal activity, high prefrontal cortex activity).27

Mnemonicsare thought to affect working memory by reducing the introduced cognitive load and increasing theefficiency of memory acquisition and encoding. They reduce cognitive load by grouping objects into a single verbalvisual cue that can be introduced into working memory. Learning is optimized when the load on working memory i

minimized, enabling long-term memory to be facilitated.28

OX 2.

MNEMONICS FOR DIAGNOSING ANXIETY DISORDERS

Generalized anxiety

disorder

Worry WARTS3Wound upWorn-outAbsentmindedRestlessTouchySleepless

Posttraumatic stress

disorder

TRAUMA5Traumatic eventRe-experienceAvoidanceUnable to functionMonth or more of symptomsArousal increased

Anxiety disorder due to a general medical conditionPhysical Diseases That Have Commonly Appeared

Anxious:PheochromocytomaDiabetes mellitusTemporal lobe epilepsyHyperthyroidismCarcinoidAlcohol withdrawalArrhythmias

Generalized anxiety

disorderWATCHERS4WorryAnxietyTension in musclesConcentration difficultyHyperarousal (or irritability)Energy lossRestlessnessSleep disturbance

Posttraumatic stressdisorder

DREAMS6Disinterest in usual activitiesRe-experienceEvent preceding symptomsAvoidanceMonth or more of symptomsSympathetic arousal


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OX 3.

MNEMONICS FOR DIAGNOSING MEDICATION ADVERSE EFFECTS

Antidepressant discontinuation syndrome

FINISH7Flu-like symptomsInsomniaNauseaImbalanceSensory disturbancesHyperarousal (anxiety/agitation)

Neuroleptic malignant syndrome

FEVER8FeverEncephalopathyVital sign instabilityElevated WBC/CPKRigidityWBC: white blood cell countCPK: creatine phosphokinase

Serotonin syndromeHARMEDHyperthermiaAutonomic instabilityRigidityMyoclonusEncephalopathyDiaphoresis

Mnemonics may use rhyme, music, or visual cues to enhance memory. Most mnemonics used in medical practice aneducation are word-based, including:

Acronymswords, each letter of which stands for a particular piece of information to be recalled (such as RIfor treatment of a sprained joint: rest, ice, compression, elevation).Acrosticssentences with the first letter of each word prompting the desired recollection (such as To Zanzibby motor car for the branches of the facial nerve: temporal, zygomatic, buccal, mandibular, cervical).Alphabetical sequences(such as ABCDE of trauma assessment: airway, breathing, circulation, disability,

exposure).29

An appropriate teaching tool?

Dozens of mnemonics addressing psychiatric diagnosis and treatment have been published, but relatively few are wiused. Psychiatric educators may resist teaching with mnemonics, believing they might erode a humanistic approachpatients by reducing psychopathology to a laundry list of symptoms and the art of psychiatric diagnosis to a chec

ox endeavor. Mnemonics that use humor may be rejected as irreverent or unprofessional.30Publishing a novelmnemonic may be viewed with disdain by some as an easy way of padding a curriculum vitae.

OX 4.

MNEMONICS FOR DIAGNOSING PERSONALITY DISORDERS

Paranoidpersonality

disorder

Schizotypal

personalitydisorder

ME PECULIAR9

Borderline

personality

Histrionic

personalitydisorder

PRAISE ME9

Dependent

personalitydisorder

RELIANCE9Reassurancerequired


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SUSPECT9SpousalinfidelitysuspectedUnforgiving(bears grudges)SuspiciousPerceives attacks

(and reactsquickly)Enemy orfriend?(suspectsassociates andfriends)Confiding inothers is fearedThreatsperceived inbenign events

Magical thinkingExperiencesunusualperceptionsParanoid ideationEccentric behavioror appearanceConstricted or

inappropriateaffectUnusual thinkingor speechLacks closefriendsIdeas of referenceAnxiety in socialsituationsRule out psychoticor pervasivedevelopmentaldisorders

disorder

IMPULSIVE10

ImpulsiveMoodinessParanoia ordissociationunder stressUnstable self-imageLabile intenserelationshipsSuicidalgesturesInappropriateangerVulnerability toabandonmentEmptiness(feelings of)

Provocative orseductive behaviorRelationshipsconsidered moreintimate than theyareAttention (need to

be the center of)Influenced easilyStyle of speech(impressionistic,lacking detail)Emotions (rapidlyshifting, shallow)Make up (physicalappearance used todraw attention toself)Emotionsexaggerated

Narcissisticpersonality disorder

GRANDIOSE11GrandioseRequires attentionArrogantNeed to be specialDreams of success andpowerInterpersonallyexploitativeOthers (unable torecognizefeelings/needs of)Sense of entitlementEnvious

ExpressingdisagreementdifficultLiferesponsibilitieassumed byothersInitiating proje

difficultAlone (feelshelpless anduncomfortablewhen alone)Nurturance (goto excessivelengths to obtaCompanionshipsought urgentlwhen arelationship enExaggerated feof being left tocare for self

Schizoidpersonality

disorder

DISTANT

9

Detached orflattened affectIndifferent tocriticism orpraiseSexualexperiences oflittle interestTasks donesolitarilyAbsence of close

friendsNeither desiresnor enjoys closerelationshipsTakes pleasurein few activities

Antisocial

personality

disorderCORRUPT9Cannot conform tolawObligationsignoredReckless disregardfor safetyRemorselessUnderhanded(deceitful)

Planninginsufficient(impulsive)Temper (irritableand aggressive)

Borderline

personalitydisorderDESPAIRER*Disturbance ofidentityEmotionallylabileSuicidalbehaviorParanoia ordissociationAbandonment(fear of)ImpulsiveRelationships

unstableEmptiness(feelings of)Rage(inappropriate)* Created byJason P.Caplan, MD

Histrionic

personalitydisorderACTRESSS*AppearancefocusedCenter of attentionTheatricalRelationships(believed to bemore intimate thanthey are)Easily influencedSeductive behavior

Shallow emotionsSpeech(impressionisticand vague)* Created by JasonP. Caplan, MD

Avoidant personality

disorder

CRINGES9Criticism or rejectionpreoccupies thoughts

in social situationsRestraint inrelationships due tofear of shameInhibited in newrelationshipsNeeds to be sure ofbeing liked beforeengaging sociallyGets aroundoccupationalactivities with need

for interpersonalcontactEmbarrassmentprevents new activityor taking risksSelf viewed asunappealing orinferior

Obsessive-compulsive

personality

disorderSCRIMPER*StubbornCannot discardworthless objeRule obsessedInflexibleMiserlyPerfectionisticExcludes leisurdue to devotion

workReluctant todelegate to oth* Created byJason P. CaplaMD


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ntire Web sites exist to share mnemonics for medical education (seeRelated Resources). Thus it is likely that trainare using them with or without their teachers supervision. Psychiatric educators need to be aware of the mnemonicheir trainees are using and to:

screen these tools for factual errors (such as incomplete diagnostic criteria)remind trainees that although mnemonics are useful, psychiatrists should approach patients as individuals withthe prejudice of a potentially pejorative label.

Our methodology

n preparing this article, we gathered numerous mnemonics (some published and some novel) designed to capture theearners attention and impart information pertinent to psychiatric diagnosis and treatment. Whenever possible, we

credited each mnemonic to its creator, butgiven the difficulty in confirming authorship of (what in many cases habecome) oral historyweve listed some mnemonics without citation.

Our list is far from complete because we likely are unaware of many mnemonics, and we have excluded some thateemed obscure, unwieldy, or redundant. We have not excluded mnemonics that some may view as pejorative but

merely report their existence. Including them does not mean that we endorse them.

his article lists 32 mnemonics related to psychiatric diagnosis. Thus, it seems odd that an informal survey of >60esidents at the Massachusetts General Hospital (MGH)/McLean Residency Training Program in Psychiatry reveale

hat most were aware of only 2 or 3 psychiatric mnemonics, typically:

SIG: E CAPS (a tool to recall the criteria for depression)DIG FAST (a list of criteria for diagnosing mania)WWHHHHIMPS (a tool for recalling life-threatening causes of delirium).

Although this unscientific survey may be biased because faculty or trainees at MGH created the above 3 mnemonicsnonetheless begs the question of what qualities make a mnemonic memorable.

Clinical Point

We included some mnemonics that may be viewed as pejorative, but that does not mean we endorse them

earning theory provides several clues. George Millers classic 1956 paper, The magical number seven, plus or minwo: some limits on our capacity for processing information, discussed the finding that 7 seems to be the upper lim

ndividual pieces of data that can be easily remembered.31Research also has shown that recruiting the limbic system

potentially through the use of humor) aids in the recall of otherwise dry, cortical information.32,33

ntuitively, it would seem that nonrepeating letters would facilitate the recall of the linked data, allowing each letter provide a distinct cue, without any clouding by redundancy. Of the 3 most popular psychiatric mnemonics, howeveronly DIG FAST fits the learning theory. It contains 7 letters, repeats no letters, and has the limbic cue of allowing thearner to imagine a person with mania digging furiously.

OX 5.

MNEMONICS FOR DIAGNOSING ADDICTION DISORDERS

Substancedependence


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ADDICTeD12Activities aregiven up orreduced

Dependence,physical:toleranceDependence,physical:withdrawalIntrapersonal(Internal)consequences,physical orpsychologicalCant cut down orcontrol useTime-consumingDuration oramount of use is

greater thanintended

Substanceabuse

WILD12Work,school, orhome roleobligationfailuresInterpersonalor socialconsequencesLegalproblemsDangeroususe

Alcohol abuse

CAGE13Have you ever felt you should CUT DOWNyour drinking? Have peopleANNOYEDyou by criticizing your drinking? Have you ever felt bad or GUILTabout your drinking? Have you ever had a drink first thing in the morning to steayour nerves or get rid of a hangover (EYE-OPENER)?

IG: E CAPS falls within the range of 7 plus or minus 2, includes a limbic cue (although often forgotten, it refers to prescription of energy capsules for depression), but repeats the letter S.

WWHHHHIMPS, with 10 letters, exceeds the recommended range, repeats the W (appearing twice) and the Happearing 4 times), and provides no clear limbic cue.

OX 6.

MNEMONICS FOR DIAGNOSING DELIRIUM

CausesI WATCH DEATH

InfectionWithdrawalAcute metabolicTraumaCNS pathologyHypoxiaDeficienciesEndocrinopathiesAcute vascularToxins or drugsHeavy metals

Life-threatening causesWWHHHHIMPS*

Wernickes encephalopathyWithdrawalHypertensive crisisHypoperfusion/hypoxia of the brainHypoglycemiaHyper/hypothermiaIntracranial process/infectionMetabolic/meningitisPoisonsStatus epilepticus* Created by Gary W. Small, MD

Deliriogenic medications

ACUTE CHANGE IN MS14AntibioticsCardiac drugsUrinary incontinence drugsTheophyllineEthanolCorticosteroidsH2 blockersAntiparkinsonian drugsNarcoticsGeriatric psychiatric drugsENT drugsInsomnia drugs


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NSAIDsMuscle relaxantsSeizure medicines

t may be that recruiting the limbic system provides the greatest likelihood of recall. Recruiting this system may addncreased valence to a particular mnemonic for a specific individual, but this same limbic valence may limit its

usefulness in a professional context.

Related resources

Free searchable database of medical mnemonics. www.medicalmnemonics.com.Robinson DJ.Mnemonics and more for psychiatry.Port Huron, MI: Rapid Psychler Press, 2001.

Copyright 2014 Frontline Medical Communications Inc., Parsippany, NJ, USA. All rights reserved.
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Mnemonics in a Mnutshell_ 32 Aids to Psychiatric Diagnosis _ Current Psychiatry