Mnemonics in a mnutshell: 32 aids to psychiatric diagnosis Clever, irreverent, or amusing, a mnemonic you remember is a lifelong learning tool ® Dowden Health Media rom SIG: E CAPS to CAGE and WWHHHHIMPS, mnemonics help practitioners and trainees recall Fimportant lists (suchCopyright as criteriaFor for depression,personal use only screening questions for alcoholism, or life-threatening causes of delirium, respectively). Mnemonics’ effi cacy rests on the principle that grouped information is easi- er 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 di- agnostic criteria have a role in psychiatric practice and IMAGES teaching. JUPITER In this article, we present 32 mnemonics to help cli- © nicians diagnose: • affective disorders (Box 1, page 28)1,2 Jason P. Caplan, MD Assistant clinical professor of psychiatry • anxiety disorders (Box 2, page 29)3-6 Creighton University School of Medicine 7,8 • medication adverse effects (Box 3, page 29) Omaha, NE • personality disorders (Box 4, page 30)9-11 Chief of psychiatry • addiction disorders (Box 5, page 32)12,13 St. Joseph’s Hospital and Medical Center Phoenix, AZ • causes of delirium (Box 6, page 32).14 We also discuss how mnemonics improve one’s Theodore A. Stern, MD Professor of psychiatry memory, based on the principles of learning theory. Harvard Medical School Chief, psychiatric consultation service Massachusetts General Hospital How mnemonics work Boston, MA A mnemonic—from the Greek word “mnemonikos” (“of memory”)—links new data with previously learned information. Mnemonics assist in learning by reducing Current Psychiatry the amount of information (“cognitive load”) that needs Vol. 7, No. 10 27 For mass reproduction, content licensing and permissions contact Dowden Health Media. 27_CPSY1008 27 9/12/08 3:20:58 PM to be stored for long-term processing and With working memory, new items of infor- retrieval.15 mation are held briefl y so that encoding Memory, defi ned as the “persistence of and eventual storage can take place. learning in a state that can be revealed at a Working memory guides decision- later time,”16 can be divided into 2 types: making and future planning and is intri- • declarative (a conscious recollection of cately related to attention.18-21 Functional facts, such as remembering a relative’s MRI and positron emission tomography Mnemonics birthday) as well as neurocognitive testing have • procedural (skills-based learning, such shown that working memory tasks ac- as riding a bicycle). tivate the prefrontal cortex and brain Declarative memory has a conscious regions specifi c to language and visuo- component and may be mediated by the spatial memory. medial temporal lobe and cortical associa- The hippocampus is thought to rapidly tion structures. Procedural memory has less absorb new information, and this data is of a conscious component; it may involve consolidated and permanently stored via the basal ganglia, cerebellum, and a variety the prefrontal cortex.22-26 Given the hippo- of cortical sensory-perceptive regions.17 campus’ limited storage capacity, new infor- mation (such as what you ate for breakfast Declarative memory can be subdivided into 3 weeks ago) will disappear if it is not re- working memory and long-term memory. peated regularly.17 BOX 1. MNEMONICS FOR DIAGNOSING AFFECTIVE DISORDERS Depression Dysthymia Mania SIG: E CAPS* HE’S 2 SAD2 DIG FAST Suicidal thoughts Hopelessness Distractibility Interests decreased Energy loss or fatigue Indiscretion Guilt Self-esteem is low Grandiosity Energy decreased 2 years minimum of depressed Flight of ideas Concentration decreased mood most of the day, for more Activity increase Appetite disturbance days than not Sleep defi cit (increased or decreased) Sleep is increased or decreased Talkativeness Psychomotor changes Appetite is increased or decreased (agitation or retardation) Decision-making or concentration Sleep disturbance is impaired (increased or decreased) * Created by Carey Gross, MD Depression Hypomania Mania C GASP DIE1 TAD HIGH DeTeR the HIGH* Concentration decreased Talkative Distractibility Guilt Attention defi cit Talkativeness Appetite Decreased need for sleep Reckless behavior Sleep disturbance High self-esteem/grandiosity Hyposomnia Psychomotor agitation or retardation Ideas that race Ideas that race Death or suicide (thoughts or acts of) Goal-directed activity increased Grandiosity Interests decreased High-risk activity Hypersexuality Energy decreased * Created by Carey Gross, MD Current Psychiatry 28 October 2008 28_CPSY1008 28 9/12/08 3:21:03 PM Long-term memory, on the other hand, is • old (low hippocampal activity, high encoded knowledge that is linked to facts prefrontal cortex activity).27 learned in the past; it is consolidated in the brain and can be readily retrieved. Mnemonics are thought to affect working Neuroimaging studies have demonstrat- memory by reducing the introduced cog- ed opposing patterns of activation in the nitive load and increasing the effi ciency of hippocampus and prefrontal cortex, de- memory acquisition and encoding. They pending on whether the memory being reduce cognitive load by grouping ob- recalled is: jects into a single verbal or visual cue that • new (high hippocampal activity, low can be introduced into working memory. prefrontal cortex activity) Learning is optimized when the load on BOX 2. MNEMONICS FOR DIAGNOSING ANXIETY DISORDERS Generalized anxiety disorder Posttraumatic stress disorder Anxiety disorderClinical due to a Point Worry WARTS3 TRAUMA5 general medicalTK condition Wound up Traumatic event Physical DiseasesClinical That Have Point Worn-out Re-experience Commonly Appeared Anxious: Absentminded Avoidance PheochromocytomaTK Restless Unable to function Diabetes mellitus Touchy Month or more of symptoms Temporal lobe epilepsy Sleepless Arousal increased Hyperthyroidism Carcinoid Alcohol withdrawal Arrhythmias Generalized anxiety disorder Posttraumatic stress disorder WATCHERS4 DREAMS6 Worry Disinterest in usual activities Anxiety Re-experience Tension in muscles Event preceding symptoms Concentration diffi culty Avoidance Hyperarousal (or irritability) Month or more of symptoms Energy loss Sympathetic arousal Restlessness Sleep disturbance BOX 3. MNEMONICS FOR DIAGNOSING MEDICATION ADVERSE EFFECTS Antidepressant discontinuation Neuroleptic malignant syndrome Serotonin syndrome syndrome FEVER8 HARMED FINISH7 Fever Hyperthermia Flu-like symptoms Encephalopathy Autonomic instability Insomnia Vital sign instability Rigidity Nausea Elevated WBC/CPK Myoclonus Imbalance Rigidity Encephalopathy Sensory disturbances Diaphoresis WBC: white blood cell count Hyperarousal (anxiety/agitation) CPK: creatine phosphokinase Current Psychiatry Vol. 7, No. 10 29 29_CPSY1008 29 9/16/08 12:06:16 PM working memory is minimized, enabling An appropriate teaching tool? long-term memory to be facilitated.28 Dozens of mnemonics addressing psychi- Mnemonics may use rhyme, music, or atric diagnosis and treatment have been visual cues to enhance memory. Most mne- published, but relatively few are widely monics used in medical practice and edu- used. Psychiatric educators may resist cation are word-based, including: teaching with mnemonics, believing they • Acronyms—words, each letter of which might erode a humanistic approach to pa- Mnemonics stands for a particular piece of information tients by reducing psychopathology to “a to be recalled (such as RICE for treatment laundry list” of symptoms and the art of of a sprained joint: rest, ice, compression, psychiatric diagnosis to a “check-box” en- elevation). deavor. Mnemonics that use humor may • Acrostics—sentences with the fi rst let- be rejected as irreverent or unprofession- ter of each word prompting the desired al.30 Publishing a novel mnemonic may be recollection (such as “To Zanzibar by mo- viewed with disdain by some as an “easy” tor car” for the branches of the facial nerve: way of padding a curriculum vitae. temporal, zygomatic, buccal, mandibular, Entire Web sites exist to share mnemon- cervical). ics for medical education (see Related • Alphabetical sequences (such as ABCDE Resources, page 33). Thus it is likely that of trauma assessment: airway, breathing, trainees are using them with or without circulation, disability, exposure).29 their teachers’ supervision. Psychiatric ed- BOX 4. MNEMONICS FOR DIAGNOSING PERSONALITY DISORDERS Paranoid personality disorder Schizotypal personality disorder Borderline personality disorder SUSPECT9 ME PECULIAR9 IMPULSIVE10 Spousal infi delity suspected Magical thinking Impulsive Unforgiving (bears grudges) Experiences unusual perceptions Moodiness Suspicious Paranoid ideation Paranoia or dissociation under stress Perceives attacks (and reacts Eccentric behavior or appearance Unstable self-image quickly) Constricted or inappropriate affect Labile intense relationships Enemy or friend? (suspects Unusual thinking or speech Suicidal gestures associates and friends) Lacks close friends Inappropriate anger Confi ding in others is feared Ideas of reference Vulnerability to abandonment Threats perceived in benign Anxiety in social situations Emptiness (feelings of) events Rule out psychotic or pervasive developmental disorders Schizoid personality disorder Antisocial personality disorder Borderline personality disorder DISTANT9 CORRUPT9 DESPAIRER* Detached or fl attened affect Cannot