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Clever, irreverent, or amusing, a mnemonic you remember is a lifelong learning tool
rom 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: • 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 one’s memory, based on the principles of learning theory.
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Jason P. Caplan, MD
Assistant clinical professor of psychiatry Creighton University School of Medicine Omaha, NE Chief of psychiatry St. Joseph’s Hospital and Medical Center Phoenix, AZ
Theodore A. Stern, MD
Professor of psychiatry Harvard Medical School Chief, psychiatric consultation service Massachusetts General Hospital Boston, MA
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
Current Psychiatry Vol. 7, No. 10
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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.15 Memory. Working memory guides decisionmaking and future planning and is intricately related to attention. cerebellum.”16 can be divided into 2 types: • declarative (a conscious recollection of facts. and a variety of cortical sensory-perceptive regions.Mnemonics to be stored for long-term processing and retrieval. 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. Declarative memory has a conscious component and may be mediated by the medial temporal lobe and cortical association structures. such as remembering a relative’s birthday) • procedural (skills-based learning.17 Declarative memory can be subdivided into working memory and long-term memory. and this data is consolidated and permanently stored via the prefrontal cortex. The hippocampus is thought to rapidly absorb new information. new items of information are held briefly so that encoding and eventual storage can take place.17 BOX 1. MD 28 Current Psychiatry October 2008 . it may involve the basal ganglia. such as riding a bicycle). With working memory. Procedural memory has less of a conscious component. new information (such as what you ate for breakfast 3 weeks ago) will disappear if it is not repeated regularly. 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.22-26 Given the hippocampus’ limited storage capacity. defined as the “persistence of learning in a state that can be revealed at a later time.
Long-term memory. 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 Current Psychiatry Vol. is encoded knowledge that is linked to facts learned in the past.27 Mnemonics are thought to affect working memory by reducing the introduced cognitive load and increasing the efficiency of memory acquisition and encoding. Learning is optimized when the load on BOX 2. it is consolidated in the brain and can be readily retrieved. They reduce cognitive load by grouping objects into a single verbal or visual cue that can be introduced into working memory. low prefrontal cortex activity) • old (low hippocampal activity. 10 29 . on the other hand. No. depending on whether the memory being recalled is: • new (high hippocampal activity. 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 TK Clinical Point Physical Diseases That Have Commonly Appeared Anxious: TK Pheochromocytoma Diabetes mellitus Temporal lobe epilepsy Hyperthyroidism Carcinoid Alcohol withdrawal Arrhythmias Clinical Point 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. Neuroimaging studies have demonstrated opposing patterns of activation in the hippocampus and prefrontal cortex. 7. high prefrontal cortex activity).
cervical). each letter of which stands for a particular piece of information to be recalled (such as RICE for treatment of a sprained joint: rest. Thus it is likely that trainees are using them with or without their teachers’ supervision. page 33). disability. • 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. enabling long-term memory to be facilitated. buccal. Most mnemonics used in medical practice and education are word-based. but relatively few are widely used.30 Publishing a novel mnemonic may be viewed with disdain by some as an “easy” way of padding a curriculum vitae. elevation). Caplan.28 Mnemonics may use rhyme. or visual cues to enhance memory. exposure). circulation. zygomatic. Psychiatric ed- BOX 4. • Alphabetical sequences (such as ABCDE of trauma assessment: airway. compression. ice. 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 working memory is minimized. Mnemonics that use humor may be rejected as irreverent or unprofessional. Entire Web sites exist to share mnemonics for medical education (see Related Resources. breathing. music. including: • Acronyms—words. mandibular.29 An appropriate teaching tool? Dozens of mnemonics addressing psychiatric diagnosis and treatment have been published. 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) 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. MD 30 Current Psychiatry October 2008 . Psychiatric educators may resist teaching with mnemonics.
psychiatrists should approach patients as individuals without the prejudice of a potentially pejorative label. unwieldy. 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. No. 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. lacking detail) Emotions (rapidly shifting. Our list is far from complete because we likely are unaware of many mnemonics. 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 Current Psychiatry Vol. we credited each mnemonic to its creator. Our methodology In preparing this article.ucators 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. This article lists 32 mnemonics related to psychiatric diagnosis. 10 31 . Caplan. Caplan. typically: • SIG: E CAPS (a tool to recall the criteria for depression) continued 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. 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 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. 7. We have not excluded mnemonics that some may view as pejorative but merely report their existence. Whenever possible. Thus. or redundant. but—given the difficulty in confirming authorship of (what in many cases has become) oral his- tory—we’ve listed some mnemonics without citation. and we have excluded some that seemed obscure. Including them does not mean that we endorse them. it seems odd that an informal survey of >60 residents at the Massachusetts General Hospital (MGH)/McLean Residency Training Program in Psychiatry revealed that most were aware of only 2 or 3 psychiatric mnemonics.
physical: tolerance Dependence.” discussed the finding that 7 seems to be the upper limit of individual pieces of data that can be easily remem- bered. includes a limbic cue BOX 5. physical or psychological Can’t cut down or control use Time-consuming Duration or amount of use is greater than intended Substance abuse WILD12 Work.31 Research also has shown that recruiting the limbic system (potentially through the use of humor) aids in the recall of otherwise dry. and has the limbic cue of allowing the learner to imagine a person with mania digging furiously.32. Of the 3 most popular psychiatric mnemonics. physical: withdrawal Intrapersonal (Internal) consequences. however.Mnemonics • DIG FAST (a list of criteria for diagnosing mania) • WWHHHHIMPS (a tool for recalling life-threatening causes of delirium). It contains 7 letters. MNEMONICS FOR DIAGNOSING ADDICTION DISORDERS Substance dependence ADDICTeD12 Activities are given up or reduced Dependence. MD Deliriogenic medications ACUTE CHANGE IN MS14 Antibiotics Cardiac drugs Urinary incontinence drugs Theophylline Ethanol Corticosteroids H2 blockers Antiparkinsonian drugs Narcotics Geriatric psychiatric drugs ENT drugs Insomnia drugs NSAIDs Muscle relaxants Seizure medicines 32 Current Psychiatry October 2008 . Learning theory provides several clues. allowing each letter to provide a distinct cue. without any clouding by redundancy. only DIG FAST fits the learning theory.33 Intuitively. George Miller’s classic 1956 paper. MNEMONICS FOR DIAGNOSING DELIRIUM Causes I WATCH DEATH Infection Withdrawal Acute metabolic Trauma CNS pathology Hypoxia Deficiencies Endocrinopathies Acute vascular Toxins or drugs Heavy metals Life-threatening causes WWHHHHIMPS* Wernicke’s encephalopathy Withdrawal Hypertensive crisis Hypoperfusion/hypoxia of the brain Hypoglycemia Hyper/hypothermia Intracranial process/infection Metabolic/meningitis Poisons Status epilepticus * Created by Gary W. it nonetheless begs the question of what qualities make a mnemonic memorable. cortical information. “The magical number seven. SIG: E CAPS falls within the range of 7 plus or minus 2. repeats no letters. school. Small. it would seem that nonrepeating letters would facilitate the recall of the linked data. Although this unscientific survey may be biased because faculty or trainees at MGH created the above 3 mnemonics. or home role obligation failures Interpersonal or social consequences Legal problems Dangerous use Alcohol abuse CAGE13 Have you ever felt you should CUT DOWN your drinking? Have people ANNOYED you by criticizing your drinking? Have you ever felt bad or GUILTY about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (EYE-OPENER)? BOX 6. plus or minus two: some limits on our capacity for processing information.
MI: Rapid Psychler Press.6:11-20. 29. repeats the W (appearing twice) and the H (appearing 4 times). J Clin Psychiatry 2001. DeLuca J. 19. 2. Eslinger P. Port Huron.22(2):25-9. Current Psychiatry Vol. Khouzam HR. WWHHHHIMPS. on board examinations. Christman DS. 2001. Hosp Community Psychiatry 1992. Brain 2001. eds. 13. Can J Psychiatry 2002. Nat Rev Neurosci 2005. Neuroimaging studies of working memory: a meta-analysis. 2004:251.47(2):197.3:7988. 33. Awh E. learning difficulty. Cognitive load during problem solving: effects on learning. Eslinger P. Abraham PF. 26. An integrative theory of prefrontal cortex function. Dissociating verbal and spatial working memory using PET.139:201-8. 7.3(4): 255-74. 30. Vogel EK.20(4):953-67. 27. Recruiting this system may add increased valence to a particular mnemonic for a specific individual. Squire LR. Related Resources • Free searchable database of medical mnemonics. Workman EA. Interactions between attention and working memory. Detecting alcoholism. Imbalance. Swanson TA. plus or minus two: some limits on our capacity for processing information. Current Psychiatry 2008.30:57-78. PA: Lippincott Williams & Wilkins. Clin Geriatr Med 1998. 11. Am J Psychiatry 2006. Coupland NJ. Criticism of mnemonic device. References 1. Clinical Point We included some mnemonics that may be viewed as pejorative.163(2):329-30.174(6):424.62(6):474-5. Mnemonics are well-suited to learning and recalling lists of signs and symptoms required for accurate psychiatric diagnosis. 2007:130. Kobori N. Fundamental components of attention. Commonly prescribed and over-the-counter remedies: causes of confusion.(although often forgotten. Acronyms for substance use disorders. Henson RN. West J Med 2001. Worry WARTS have generalized anxiety disorder. PA: Saunders.14:101-27. WATCHERS: recognizing generalized anxiety disorder. Learn Instr 1994. • Robinson DJ. 14. 7. 9. with 10 letters. Lippman LG. Sweller J. Flu-like symptoms. Ewing JA. Neuroscience 2006. 12. Psychotherapeutic agents in older adults. Nurse Educ 1997. Memory and brain.59(5):255. Cogn Sci 1988. Identify neuroleptic malignant syndrome with FEVER. medicalmnemonics.24:167-202. Smith EE. 1987. and instructional design. Cohen JD. Cereb Cortex 1996. and provides no clear limbic cue. PET evidence for a modal verbal working memory system. Turner RL. 4th ed.139:23-36. Principles and practice of behavioral neurology and neuropsychology.com. Effects of humor on sentence memory. NY: Oxford University Press. Awh E. The organization of recent and remote memories.12(1):257-85. and Hyperarousal (anxiety/agitation). Dunn ML. Smith EE. Psychol Rev 1956. et al. Working memory as an emergent property of the mind and brain. Lauber E. 15.6:119-30. Flaherty JH. J Gen Psychol 2000. Miller GA. 17.61(6):447.147(7):963-4. The magical number seven. Borderline mnemonic.154(9): 1321. Miller EK. 18. exceeds the recommended range. Kim SI. 22. www. 25. Wager TD. Quinn DK. Senger HL. Lengenfelder J. Christensen RC. 32. Pinkofsky HB. Short DD. 21. Ann Rev Neurosci 2001. but that does not mean we endorse them Bottom Line Recollecting diagnostic criteria is useful in clinical practice.48(9):1197-8. Cognitive load theory. J Exp Psychol Learn Mem Cogn 1994. Knudson EI. 4. 8. Neuroscience 2006. eds. Bontempi B. 10. Contextual connections within puns: effects on perceived humor and memory. Unleashing the power of memory: the mighty mnemonic. JAMA 1984. 31. Dash PK. Underground clinical vignettes step 2: psychiatry. Cogn Affect Behav Neurosci 2003. Frontal lobes and human memory: Insights from functional neuroimaging. and for insurance reimbursement. New mnemonic for depressive symptoms. but this same limbic valence may limit its usefulness in a professional context. 6. Am J Psychiatry 1990.124:84981. Koeppe RA. Shirley ER. 28. Neuroimage 1996. 20. 23. Insomnia. The CAGE questionnaire. Philadelphia.4(7):102. Beitz JM. but repeats the letter S. Larson EW. Berber MJ.252(14):1905-7. In: Rizzo M.14:554-63. Jonides J. Current Psychiatry 2005. Schmidt SR. Schumacher EH.43(6):642-4. 16. Caplan JP. Oh SH. Mnemonics for eight DSM-III-R disorders. Mnemonics for DSM-IV personality disorders. Morse JH. it refers to the prescription of energy capsules for depression). Fletcher PC.63:81-97. Mnemonics and more for psychiatry. A simple mnemonic for the diagnostic criteria for post-traumatic stress disorder. 5. Bogenschutz MP. J Clin Psychiatry 1998. FINISH: remembering the discontinuation syndrome. Nausea. Sweller J. It may be that recruiting the limbic system provides the greatest likelihood of recall.7(3):120. Berber MJ. No. Am J Psychiatry 1997. “HE’S 2 SAD” detects dysthymic disorder. Sensory disturbances.4:295-312. 24. New York. Molecular activity underlying working memory. Memory and learning. et al. Philadelphia. Ann Rev Neurosci 2007. Frankland PW. Moore AN. Psychiatr Serv 1997. Postle BR. Learn Mem 2007. 3. 10 33 .127(2):185-97. J Clin Psychiatry 2000.
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