Mneumonics_PsychDx

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Current Psychiatry Vol. 7, No. 10 27

Mnemonics in a mnutshell:32 aids to psychiatric diagnosis

Clever, irreverent, or amusing,a mnemonic you rememberis a lifelong learning tool

Jason P. Caplan, MD

Assistant clinical professor of psychiatryCreighton University School of MedicineOmaha, NEChief of psychiatrySt. Josephs Hospital and Medical CenterPhoenix, AZ

Theodore A. Stern, MDProfessor of psychiatryHarvard Medical SchoolChief, psychiatric consultation serviceMassachusetts General HospitalBoston, MA

From SIG: E CAPS to CAGE and WWHHHHIMPS,mnemonics help practitioners and trainees recallimportant lists (such as criteria for depression,screening questions for alcoholism, or life-threateningcauses of delirium, respectively). Mnemonics ef cacy

rests on the principle that grouped information is easi-er to remember than individual points of data. Not everyone loves mnemonics, but recollectingdiagnostic criteria is useful in clinical practice andresearch, on board examinations, and for insurancereimbursement. Thus, tools that assist in recalling di-agnostic criteria have a role in psychiatric practice andteaching.

In this article, we present 32 mnemonics to help cli-nicians diagnose: affective disorders ( Box 1, page 28 )1,2

anxiety disorders ( Box 2, page 29 )3-6 medication adverse effects ( Box 3, page 29 )7,8

personality disorders ( Box 4, page 30 )9-11

addiction disorders ( Box 5, page 32 )12,13

causes of delirium ( Box 6, page 32 ).14

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

How mnemonics work

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

J U P I T E R I M A G E S


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Current Psychiatry October 200828

Mnemonics

BOX 1. MNEMONICS FOR DIAGNOSING AFFECTIVE DISORDERS

DepressionSIG: E CAPS *S uicidal thoughtsInterests decreased

GuiltEnergy decreasedC oncentration decreased

A ppetite disturbance(increased or decreased)

P sychomotor changes(agitation or retardation)

S leep disturbance(increased or decreased)

* Created by Carey Gross, MD

DysthymiaHES 2 SAD 2

HopelessnessEnergy loss or fatigue

S elf-esteem is low2 years minimum of depressed

mood most of the day, for more days than notS leep is increased or decreased

A ppetite is increased or decreasedDecision-making or concentration

is impaired

ManiaDIG FASTDistractibilityIndiscretion

GrandiosityFlight of ideas

A ctivity increaseS leep de citTalkativeness

DepressionC GASP DIE 1

C oncentration decreasedGuilt

A ppetiteS leep disturbanceP sychomotor agitation or retardationDeath or suicide (thoughts or acts of)Interests decreasedEnergy decreased

HypomaniaTAD HIGHTalkative

A ttention de citDecreased need for sleepHigh self-esteem/grandiosityIdeas that raceGoal-directed activity increasedHigh-risk activity

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

to be stored for long-term processing andretrieval. 15

Memory, de ned as the persistence oflearning in a state that can be revealed at alater time, 16 can be divided into 2 types:

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 themedial temporal lobe and cortical associa-tion structures. Procedural memory has lessof a conscious component; it may involvethe basal ganglia, cerebellum, and a varietyof cortical sensory-perceptive regions. 17

Declarative memory can be subdivided intoworking memory and long-term memory.

With working memory, new items of infor-mation are held brie y so that encodingand eventual storage can take place.

Working memory guides decision-making and future planning and is intri-cately related to attention. 18-21 Functional

MRI and positron emission tomographyas well as neurocognitive testing haveshown that working memory tasks ac-tivate the prefrontal cortex and brainregions speci c to language and visuo-spatial memory. The hippocampus is thought to rapidlyabsorb new information, and this data isconsolidated and permanently stored viathe prefrontal cortex. 22-26 Given the hippo-campus limited storage capacity, new infor-

mation (such as what you ate for breakfast3 weeks ago) will disappear if it is not re-peated regularly. 17


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Current Psychiatry October 200830

Mnemonics

BOX 4. MNEMONICS FOR DIAGNOSING PERSONALITY DISORDERS

working memory is minimized, enablinglong-term memory to be facilitated. 28

Mnemonics may use rhyme, music, orvisual cues to enhance memory. Most mne-monics used in medical practice and edu-cation are word-based, including:

Acronyms words, each letter of whichstands for a particular piece of informationto be recalled (such as RICE for treatmentof a sprained joint: rest, ice, compression,elevation).

Acrostics sentences with the rst let-ter of each word prompting the desiredrecollection (such as To Zanzibar by mo-tor car for the branches of the facial nerve:temporal, zygomatic, buccal, mandibular,cervical).

Alphabetical sequences (such as ABCDEof trauma assessment: airway, breathing,circulation, disability, exposure). 29

An appropriate teaching tool?Dozens of mnemonics addressing psychi-atric diagnosis and treatment have beenpublished, but relatively few are widelyused. Psychiatric educators may resistteaching with mnemonics, believing they

might erode a humanistic approach to pa-tients by reducing psychopathology to alaundry list of symptoms and the art ofpsychiatric diagnosis to a check-box en-deavor. Mnemonics that use humor may be rejected as irreverent or unprofession-al.30 Publishing a novel mnemonic may beviewed with disdain by some as an easyway of padding a curriculum vitae. Entire Web sites exist to share mnemon-ics for medical education (see Related

Resources, page 33 ). Thus it is likely thattrainees are using them with or withouttheir teachers supervision. Psychiatric ed-

Paranoid personality disorderSUSPECT 9

S pousal in delity suspectedUnforgiving (bears grudges)

S uspiciousP erceives attacks (and reacts quickly)Enemy or friend? (suspects

associates and friends)C on ding in others is fearedThreats perceived in benign events

Schizotypal personality disorderME PECULIAR 9 Magical thinkingExperiences unusual perceptions

P aranoid ideationEccentric behavior or appearanceC onstricted or inappropriate affectUnusual thinking or speechLacks close friendsIdeas of reference

A nxiety in social situationsRule out psychotic or pervasive

developmental disorders

Borderline personality disorderIMPULSIVE 10

ImpulsiveMoodiness

P aranoia or dissociation under stressUnstable self-imageLabile intense relationshipsS uicidal gesturesInappropriate anger

V ulnerability to abandonmentEmptiness (feelings of)

Schizoid personality disorderDISTANT 9

Detached or attened affectIndifferent to criticism or praiseS exual experiences of little interestTasks done solitarily

A bsence of close friendsNeither desires nor enjoys close relationshipsTakes pleasure in few activities

Antisocial personality disorderCORRUPT 9

C annot conform to lawObligations ignoredReckless disregard for safetyRemorselessUnderhanded (deceitful)P lanning insuf cient (impulsive)Temper (irritable and aggressive)

Borderline personality disorderDESPAIRER *Disturbance of identityEmotionally labileS uicidal behaviorP aranoia or dissociation

A bandonment (fear of)ImpulsiveRelationships unstableEmptiness (feelings of)Rage (inappropriate)* Created by Jason P. Caplan, MD


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Current Psychiatry Vol. 7, No. 10 31

ucators need to be aware of the mnemonicstheir trainees are using and to:

screen these tools for factual errors(such as incomplete diagnostic criteria)

remind trainees that although mne-monics are useful, psychiatrists should ap-

proach patients as individuals without theprejudice of a potentially pejorative label.

Our methodologyIn preparing this article, we gatherednumerous mnemonics (some publishedand some novel) designed to capture thelearners attention and impart informa-tion pertinent to psychiatric diagnosis andtreatment. Whenever possible, we credited

each mnemonic to its creator, butgiventhe dif culty in con rming authorship of(what in many cases has become) oral his-

toryweve listed some mnemonics with-out citation.

Our list is far from complete because welikely are unaware of many mnemonics,and we have excluded some that seemedobscure, unwieldy, or redundant. We have

not excluded mnemonics that some mayview as pejorative but merely report theirexistence. Including them does not meanthat we endorse them.

This article lists 32 mnemonics relatedto psychiatric diagnosis. Thus, it seemsodd that an informal survey of >60 resi-dents at the Massachusetts General Hos-pital (MGH)/McLean Residency TrainingProgram in Psychiatry revealed that mostwere aware of only 2 or 3 psychiatric mne-

monics, typically: SIG: E CAPS (a tool to recall the criteria

for depression)

Histrionic personality disorderPRAISE ME 9

P rovocative or seductive behaviorRelationships considered more

intimate than they are A ttention (need to be the center of)In uenced easilyS tyle of speech (impressionistic,

lacking detail)Emotions (rapidly shifting, shallow)Make up (physical appearance

used to draw attention to self)Emotions exaggerated

Narcissistic personality disorderGRANDIOSE 11

GrandioseRequires attention

A rrogantNeed to be specialDreams of success and powerInterpersonally exploitativeO thers (unable to recognize

feelings/needs of)S ense of entitlementEnvious

Dependent personality disorderRELIANCE 9

Reassurance requiredExpressing disagreement dif cult

Life responsibilities assumed by othersInitiating projects dif cult A lone (feels helpless and uncomfortable when alone)Nurturance (goes to excessive

lengths to obtain)C ompanionship sought urgently

when a relationship endsExaggerated fears of being left

to care for self

Histrionic personality disorder ACTRESSS * A ppearance focusedC enter of attentionTheatricalRelationships (believed to be

more intimate than they are)Easily in uencedS eductive behaviorS hallow emotionsS peech (impressionistic and vague)* Created by Jason P. Caplan, MD

Avoidant personality disorderCRINGES 9

C riticism or rejection preoccupiesthoughts in social situations

Restraint in relationships due tofear of shame

Inhibited in new relationshipsNeeds to be sure of being liked

before engaging sociallyGets around occupational activities

with need for interpersonal contactEmbarrassment prevents new

activity or taking risksS elf viewed as unappealing or inferior

Obsessive-compulsive personalitydisorderSCRIMPER *S tubbornC annot discard worthless objectsRule obsessedIn exibleMiserlyP erfectionisticExcludes leisure due to devotion

to workReluctant to delegate to others* Created by Jason P. Caplan, MD

continued


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