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Evidence-Based Reviews


Mnemonics in a mnutshell: 32 aids to psychiatric diagnosis

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

Vol. 7, No. 10 / October 2008

From SIG: E CAPS to CAGE and WWHHHHIMPS, mnemonics help practitioners and trainees recall important lists (such as criteria for depression, screening questions for alcoholism, or life-threatening causes of delirium, respectively). Mnemonics’ efficacy rests on the principle that grouped information is easier to remember than individual points of data.

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

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

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

How mnemonics work

A mnemonic—from the Greek word “mnemonikos” (“of memory”)—links new data with previously learned information. Mnemonics assist in learning by reducing the amount of information (“cognitive load”) that needs to be stored for long-term processing and retrieval.15

Memory, defined as the “persistence of learning in a state that can be revealed at a later time,”16 can be divided into 2 types:

  • declarative (a conscious recollection of facts, such as remembering a relative’s 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 cortical association 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

BOX 1.

MNEMONICS FOR DIAGNOSING AFFECTIVE DISORDERS

Depression
SIG: E CAPS*
Suicidal thoughts
Interests decreased
Guilt
Energy decreased
Concentration decreased
Appetite disturbance (increased or decreased)
Psychomotor changes (agitation or retardation)
Sleep disturbance (increased or decreased)
* Created by Carey Gross, MD

Dysthymia
HE’S 2 SAD2
Hopelessness
Energy loss or fatigue
Self-esteem is low
2 years minimum of depressed mood most of the day, for more days than not
Sleep is increased or decreased
Appetite is increased or decreased
Decision-making or concentration is impaired

Mania
DIG FAST
Distractibility
Indiscretion
Grandiosity
Flight of ideas
Activity increase
Sleep deficit
Talkativeness

Depression
C GASP DIE1
Concentration decreased
Guilt
Appetite
Sleep disturbance
Psychomotor agitation or retardation
Death or suicide (thoughts or acts of)
Interests decreased
Energy decreased

Hypomania
TAD HIGH
Talkative
Attention deficit
Decreased need for sleep
High self-esteem/grandiosity
Ideas that race
Goal-directed activity increased
High-risk activity

Mania
DeTeR the HIGH*
Distractibility
Talkativeness
Reckless behavior
Hyposomnia
Ideas that race
Grandiosity
Hypersexuality
* Created by Carey Gross, MD

Declarative memory can 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 place.

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

The hippocampus is thought to rapidly absorb new information, and this data is consolidated and permanently stored via the prefrontal cortex.22-26 Given the hippocampus’ limited storage capacity, new information (such as what you ate for 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 is consolidated in the brain and can be readily retrieved. Neuroimaging studies have demonstrated opposing patterns of activation 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

Mnemonics are thought to affect working memory by reducing the introduced cognitive load and increasing the efficiency of memory acquisition and encoding. They reduce cognitive load by grouping objects into a single verbal or visual cue that can be introduced into working memory. Learning is optimized when the load on working memory is minimized, enabling long-term memory to be facilitated.28

BOX 2.

MNEMONICS FOR DIAGNOSING ANXIETY DISORDERS

Generalized anxiety disorder
Worry WARTS3
Wound up
Worn-out
Absentminded
Restless
Touchy
Sleepless

Posttraumatic stress disorder
TRAUMA5
Traumatic event
Re-experience
Avoidance
Unable to function
Month or more of symptoms
Arousal increased

Anxiety disorder due to a general medical condition
Physical Diseases That Have Commonly Appeared Anxious:
Pheochromocytoma
Diabetes mellitus
Temporal lobe epilepsy
Hyperthyroidism
Carcinoid
Alcohol withdrawal
Arrhythmias

Generalized anxiety disorder
WATCHERS4
Worry
Anxiety
Tension in muscles
Concentration difficulty
Hyperarousal (or irritability)
Energy loss
Restlessness
Sleep disturbance

Posttraumatic stress disorder
DREAMS6
Disinterest in usual activities
Re-experience
Event preceding symptoms
Avoidance
Month or more of symptoms
Sympathetic arousal

 

BOX 3.

MNEMONICS FOR DIAGNOSING MEDICATION ADVERSE EFFECTS

Antidepressant discontinuation syndrome
FINISH7
Flu-like symptoms
Insomnia
Nausea
Imbalance
Sensory disturbances
Hyperarousal (anxiety/agitation)

Neuroleptic malignant syndrome
FEVER8
Fever
Encephalopathy
Vital sign instability
Elevated WBC/CPK
Rigidity
WBC: white blood cell count
CPK: creatine phosphokinase

Serotonin syndrome
HARMED
Hyperthermia
Autonomic instability
Rigidity
Myoclonus
Encephalopathy
Diaphoresis

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

  • Acronyms—words, each letter of which stands for a particular piece of information to be recalled (such as RICE for treatment of a sprained joint: rest, ice, compression, elevation).
  • Acrostics—sentences with the first letter of each word prompting the desired recollection (such as “To Zanzibar by 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 widely used. Psychiatric educators may resist teaching with mnemonics, believing they might erode a humanistic approach to patients by reducing psychopathology to “a laundry list” of symptoms and the art of psychiatric diagnosis to a “check-box” endeavor. Mnemonics that use humor may be rejected as irreverent or unprofessional.30 Publishing a novel mnemonic may be viewed with disdain by some as an “easy” way of padding a curriculum vitae.

BOX 4.

MNEMONICS FOR DIAGNOSING PERSONALITY DISORDERS

Paranoid personality disorder
SUSPECT9
Spousal infidelity suspected
Unforgiving (bears grudges)
Suspicious
Perceives attacks (and reacts quickly)
Enemy or friend? (suspects associates and friends)
Confiding in others is feared
Threats perceived in benign events

Schizotypal personality disorder
ME PECULIAR9
Magical thinking
Experiences unusual perceptions
Paranoid ideation
Eccentric behavior or appearance
Constricted or inappropriate affect
Unusual thinking or speech
Lacks close friends
Ideas of reference
Anxiety in social situations
Rule out psychotic or pervasive developmental disorders

Borderline personality disorder
IMPULSIVE10
Impulsive
Moodiness
Paranoia or dissociation under stress
Unstable self-image
Labile intense relationships
Suicidal gestures
Inappropriate anger
Vulnerability to abandonment
Emptiness (feelings of)

Histrionic personality disorder
PRAISE ME9
Provocative or seductive behavior
Relationships considered more intimate than they are
Attention (need to be the center of)
Influenced easily
Style of speech (impressionistic, lacking detail)
Emotions (rapidly shifting, shallow)
Make up (physical appearance used to draw attention to self)
Emotions exaggerated

Narcissistic personality disorder
GRANDIOSE11
Grandiose
Requires attention
Arrogant
Need to be special
Dreams of success and power
Interpersonally exploitative
Others (unable to recognize feelings/needs of)
Sense of entitlement
Envious

Dependent personality disorder
RELIANCE9
Reassurance required
Expressing disagreement difficult
Life responsibilities assumed by others
Initiating projects difficult
Alone (feels helpless and uncomfortable when alone)
Nurturance (goes to excessive lengths to obtain)
Companionship sought urgently when a relationship ends
Exaggerated fears of being left to care for self

Schizoid personality disorder
DISTANT9
Detached or flattened affect
Indifferent to criticism or praise
Sexual experiences of little interest
Tasks done solitarily
Absence of close friends
Neither desires nor enjoys close relationships
Takes pleasure in few activities

Antisocial personality disorder
CORRUPT9
Cannot conform to law
Obligations ignored
Reckless disregard for safety
Remorseless
Underhanded (deceitful)
Planning insufficient (impulsive)
Temper (irritable and aggressive)

Borderline personality disorder
DESPAIRER*
Disturbance of identity
Emotionally labile
Suicidal behavior
Paranoia or dissociation
Abandonment (fear of)
Impulsive
Relationships unstable
Emptiness (feelings of)
Rage (inappropriate)
* Created by Jason P. Caplan, MD

Histrionic personality disorder
ACTRESSS*
Appearance focused
Center of attention
Theatrical
Relationships (believed to be more intimate than they are)
Easily influenced
Seductive behavior
Shallow emotions
Speech (impressionistic and vague)
* Created by Jason P. Caplan, MD

Avoidant personality disorder
CRINGES9
Criticism or rejection preoccupies thoughts in social situations
Restraint in relationships due to fear of shame
Inhibited in new relationships
Needs to be sure of being liked before engaging socially
Gets around occupational activities with need for interpersonal contact
Embarrassment prevents new activity or taking risks
Self viewed as unappealing or inferior

Obsessive-compulsive personality disorder
SCRIMPER*
Stubborn
Cannot discard worthless objects
Rule obsessed
Inflexible
Miserly
Perfectionistic
Excludes leisure due to devotion to work
Reluctant to delegate to others
* Created by Jason P. Caplan, MD

Entire Web sites exist to share mnemonics for medical education (see Related Resources). Thus it is likely that trainees are using them with or without their teachers’ supervision. Psychiatric educators need to be aware of the mnemonics their 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 without the prejudice of a potentially pejorative label.

Our methodology

In preparing this article, we gathered numerous mnemonics (some published and some novel) designed to capture the learner’s attention and impart information pertinent to psychiatric diagnosis and treatment. Whenever possible, we credited each mnemonic to its creator, but—given the difficulty in confirming authorship of (what in many cases has become) oral history—we’ve listed some mnemonics without citation.

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