Mnemonics in a mnutshell: 32 aids to psychiatric diagnosis

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:

• 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 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.

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.

BOX 3.

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.

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.

Our list is far from complete because we likely are unaware of many mnemonics, and we have excluded some that seemed 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.

This article lists 32 mnemonics related to psychiatric diagnosis. Thus, 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, 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 mnemonics, it nonetheless begs the question of what qualities make a mnemonic memorable.

Learning theory provides several clues. George Miller’s classic 1956 paper, “The magical number seven, plus or minus two: some limits on our capacity for processing information,” discussed the finding that 7 seems to be the upper limit of individual pieces of data that can be easily remembered.³¹ Research 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

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

BOX 5.

SIG: E CAPS falls within the range of 7 plus or minus 2, includes a limbic cue (although often forgotten, it refers to the 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 H (appearing 4 times), and provides no clear limbic cue.

BOX 6.

It may be that recruiting the limbic system provides the greatest likelihood of recall. Recruiting this system may add increased 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.

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:

• 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 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.

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.

BOX 3.

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.

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.

Our list is far from complete because we likely are unaware of many mnemonics, and we have excluded some that seemed 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.

This article lists 32 mnemonics related to psychiatric diagnosis. Thus, 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, 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 mnemonics, it nonetheless begs the question of what qualities make a mnemonic memorable.

Learning theory provides several clues. George Miller’s classic 1956 paper, “The magical number seven, plus or minus two: some limits on our capacity for processing information,” discussed the finding that 7 seems to be the upper limit of individual pieces of data that can be easily remembered.³¹ Research 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

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

BOX 5.

SIG: E CAPS falls within the range of 7 plus or minus 2, includes a limbic cue (although often forgotten, it refers to the 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 H (appearing 4 times), and provides no clear limbic cue.

BOX 6.

It may be that recruiting the limbic system provides the greatest likelihood of recall. Recruiting this system may add increased 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.

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:

• 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 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.

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.

BOX 3.

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.

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.

Our list is far from complete because we likely are unaware of many mnemonics, and we have excluded some that seemed 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.

This article lists 32 mnemonics related to psychiatric diagnosis. Thus, 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, 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 mnemonics, it nonetheless begs the question of what qualities make a mnemonic memorable.

Learning theory provides several clues. George Miller’s classic 1956 paper, “The magical number seven, plus or minus two: some limits on our capacity for processing information,” discussed the finding that 7 seems to be the upper limit of individual pieces of data that can be easily remembered.³¹ Research 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

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

BOX 5.

SIG: E CAPS falls within the range of 7 plus or minus 2, includes a limbic cue (although often forgotten, it refers to the 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 H (appearing 4 times), and provides no clear limbic cue.

BOX 6.

It may be that recruiting the limbic system provides the greatest likelihood of recall. Recruiting this system may add increased 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.