Mnemonic for Elements of the Mental Status Examination:

The MSE has roughly seven components. This mnemonic will

help you to remember them:
All Borderline Subjects Are Tough, Troubled Characters
Appearance
Behavior
Speech
Affect
Thought process
Thought content
Cognitive examination
MEMORIZE THE SEVEN MAJOR DIAGNOSTIC CATEGORIES OF DSM IV-R.

Depressed Patients Sound Anxious, So Claim Psychiatrists.

Depression and other mood disorders (major depression, bipolar disorder, dysthymia)
Psychotic disorders (schizophrenia, schizoaffective disorder, delusional disorder)
Substance abuse disorders (alcohol and drug abuse, psychiatric syndromes induced by
drug and alcohol use)
Anxiety disorders [panic disorder, agoraphobia, generalized anxiety disorder (GAD),
obsessive-compulsive disorder (OCD)]
Somatoform disorders (somatization disorder, eating disorders)
Cognitive disorders (dementia, mental retardation, ADHD)
Personality disorders

Notice that these categories deviate somewhat from DSM-IV-TR dogma. For example, I
call ADHD a cognitive disorder, whereas the DSM-IV-TR classifies it as a disorder of
infancy, childhood, and adolescence. Also, I classify eating disorders under
somatoform disorders, whereas the DSM-IV-TR puts them in a separate chapter. My
purpose here is not to create a new classification of psychiatric disorders but simply to
rearrange them into seven categories for ease of memorization.
Keep the mnemonic Depressed Patients Sound
Anxious, So Claim Psychiatrists in mind as you listen
to your patient. Does she appear depressed or manic?
Is she speaking coherently, and is her reality testing
good? Does she seem anxious? Doe she seem sharp
or cognitively impaired? Is she beginning the
interview complaining of numerous somatic
symptoms? Does she have alcohol on her breath?
Does she seem inappropriately angry or entitled? You
will quickly be able to generate a mental list of likely
diagnoses, which you should follow up on later in the
interview with appropriate screening and probing
questions.
FOCUS ON POSITIVE CRITERIA
Now that you've memorized the major disorders, you need to memorize
the diagnostic criteria. Begin by disregarding the voluminous exclusions
and modifiers listed by the DSM-IV-TR and instead focus on the actual
behaviors and affects needed to make the diagnosis.

For example, under schizophrenia in the DSM-IV-TR are six categories of

criteria, labeled A through F. B is the usual proviso that the disorder
must cause significant dysfunction, which is true for all the disorders, so
you don't need to memorize it.
D tells you to rule out schizoaffective and mood disorder before you
diagnose schizophrenia, another obvious piece of information; don't use
up valuable neurons memorizing it.
E reminds you to rule out substance abuse or a medical condition, which
you should do before making any diagnosis,
and F deals with the arcane issue of diagnosing schizophrenia in
someone who's autistic. So, only two essential criteria are left:
A (symptoms) and C (duration).
Mood Disorders
Major Depression: SIG E CAPS (apart from Dep mood/ Anhedonia= must)

Four out of the following eight, with depressed mood or anhedonia, for 2 weeks
signify major depression:
Sleep disorder (either increased or decreased sleep)
Interest deficit (anhedonia)
Guilt (worthlessness, hopelessness, regret)
Energy deficit
Concentration deficit
Appetite disorder (either decreased or increased appetite)
Psychomotor retardation or agitation
Suicidality

This mnemonic, devised by Dr. Cary Gross of the MGH Department of Psychiatry, refers
to what might be written on a prescription sheet for a depressed, anergic patient: SIG:
Energy CAPSules. Each letter refers to one of the major diagnostic criteria for a major
depressive disorder. To meet the criteria for an episode of major depression, your
patient must have had four of the preceding symptoms and depressed mood or
anhedonia for at least 2 weeks.
Dysthymia: ACHEWS
Two out of these six, with depressed mood, for 2 years signify
dysthymia:

Appetite disorder (either decreased or increased)

Concentration deficit
Hopelessness
Energy deficit
Worthlessness
Sleep disorder (either increased or decreased)

The dysthymic patient is allergic to happiness;

hence, the mnemonic refers to a dysthymic patient's (misspelled)
sneezes (achoos) on exposure to happiness. To meet the criteria, the
patient must have had 2 years of depressed mood with two of the six
symptoms in the mnemonic.
Manic Episode: DIGFAST
Elevated mood with three of these seven, or irritable mood with four of
these seven, for 1 week signify a manic episode:
Distractibility
Indiscretion (DSM-IV-TR's excessive involvement in pleasurable
activities)
Grandiosity
Flight of ideas
Activity increase
Sleep deficit (decreased need for sleep)
Talkativeness (pressured speech)

DIGFAST apparently refers to the speed with which a manic patient

would dig a hole if put to the task. A complication in the diagnosis is that
if the mood is primarily irritable, four of seven criteria must be met to
qualify.
Psychotic Disorders - Schizophrenia:
Delusions Herald Schizophrenic's Bad News
Two of these five for 1 month, with 5 months prodromal or residual
symptoms, signify schizophrenia:

Delusions
Hallucinations
Speech disorganization
Behavior disorganization
Negative symptoms

To meet the criteria for schizophrenia, patients must have had some
disturbance for 6 months. During at least 1 month of this period, they
must have two of the symptoms listed in the mnemonic; the other 5
months may include similar symptoms in attenuated form (i.e.,
prodromal or residual symptoms).
Substance Abuse
The same mnemonic, Tempted With Cognac, is used for criteria for any drug or alcohol
dependence:
Tolerance (i.e., a need for increasing amounts of alcohol to achieve intoxication)
Withdrawal syndrome has occurred
Loss of Control of alcohol use (encompasses the following five criteria):
Alcohol is often ingested in larger amounts than the patient intended.
The patient has tried, unsuccessfully, to cut down.
A great deal of time is spent in activities related to obtaining or recovering from the effects
of alcohol.
Important social, occupational, or recreational activities are given up or reduced because of
alcohol use.
Alcohol use is continued despite the patient's knowledge of significant physical or
psychological problems caused by its use.
Three of the seven criteria listed above are required for diagnosis.

For alcohol dependence, the CAGE questionnaire is often used:

Have you felt you should Cut back on your drinking?
Has anybody Annoyed you with comments on your drinking?
Have you felt Guilty about your drinking?
Have you ever had an Eye-opener in the morning to get rid of a hangover?
Two or more affirmative answers indicate a high probability of alcohol dependence
Anxiety Disorders - Panic Attack (4 of 13)
With so many separate criteria to remember (13 total), trying
to recall them with an acronym or phrase is not practical. My
trick instead is to break the symptoms down into three
clusters: (a) the heart, (b) breathlessness, and (c) fear. To
remember them, I visualize a panicking patient clutching his
chest (heart cluster), hyperventilating (breathlessness
cluster), and shaking with fear (fear cluster). Finally, I imagine
him screaming out, Three-five-five! Three-five-five!
presumably as a way of distracting himself from the panic
attack. The numbers refer to the number of criteria in each
cluster: The heart cluster has three criteria, and the other two
clusters have five each.
I admit that this all sounds hokey, but believe me, you'll never
forget the criteria if you do it!
Heart Cluster: Three
I think of symptoms that often accompany a heart attack:
Palpitations
Chest pain
Nausea
Breathlessness Cluster: Five
I think of symptoms associated with hyperventilation, which include dizziness, lightheadedness,
tingling of the extremities or lips (paresthesias), and chills or hot flashes.
Shortness of breath
Choking sensation
Dizziness
Paresthesias
Chills or hot flashes
Fear Cluster: Five
I associate shaking and sweating with fear. To remember derealization, think of it as a way of
psychologically escaping panic.
Fear of dying
Fear of going crazy
Shaking
Sweating
Derealization or depersonalization
Aside from remembering the cluster names, remember the pattern 3-5-5 to keep from missing
any of the 13 criteria. Your patient must have experienced four symptoms to meet the criteria
for a full-scale panic attack.
Agoraphobia
I have no mnemonic for agoraphobia, because
there are really only two criteria:

a fear of being in places where escape might be

difficult
and efforts to avoid such places.
Obsessive-Compulsive Disorder
The requirement for the diagnosis of OCD is the presence of
obsessions, compulsions, or both to a degree that causes
significant dysfunction. The definitions of obsessions and
compulsions are easily learned and remembered , so a
mnemonic is not necessary. Instead, I have chosen some of
the most common symptoms seen in clinical practice; none
of them is specifically required to be present by DSM-IV-TR.
Washing and Straightening Make Clean Houses:
Washing
Straightening (ordering rituals)
Mental rituals (e.g., magical words, numbers)
Checking
Hoarding
Posttraumatic Stress Disorder
The PTSD patient Remembers Atrocious Nuclear Attacks.
Reexperiencing the trauma via intrusive memories,
flashbacks, or nightmares (one of which is required for
diagnosis)
Avoidance of stimuli associated with trauma and Numbing of
general responsiveness
(e.g., avoiding things associated with the trauma, amnesia for
the trauma, restricted affect and activities, detachment, and
foreshortened future; one required for diagnosis)
Symptoms of increased Arousal, such as insomnia, irritability,
hypervigilance, startle response, and poor concentration (two
required for diagnosis)
The disturbance lasts at least 1 month
Generalized Anxiety Disorder (Three of Six)
The first part of the diagnosis of GAD is easy: The patient has worried
excessively about something for 6 months. The hard part is
remembering the six anxiety symptoms, three of which must be
present. The following mnemonic is based on the idea that Macbeth
had GAD before and after killing King Duncan:
Macbeth Frets Constantly Regarding Illicit Sins:
Muscle tension
Fatigue
Concentration problems
Restlessness, feeling on edge
Irritability
Sleep problems
If this elaborate acronym isn't to your liking, an alternative is imagining
what you would experience if you were constantly worrying about
something or other. You'd have insomnia, leading to daytime fatigue.
Fatigue in turn would cause irritability and problems concentrating, and
constant worry would cause muscle tension and restlessness.
Somatoform Disorders- Somatization Disorder
Recipe 4 pain: convert 2 stomachs to 1 sex (eight of
eight symptoms, onset before age 30 years).
The diagnosis of somatization disorder requires a
number of medically unexplained symptoms with
onset before age 30 years. There must be four pain
symptoms (4 pain), one conversion symptom
(convert), two gastrointestinal symptoms (2
stomachs), and one sexual symptom (1 sex). This
nonsensical mnemonic will lodge these criteria in your
brain forever.
Bulimia Nervosa
Bulimics OverConsume Pastries (four of these):
Bingeing
Out-of-control feeling while eating
Concern with body shape
Purging
Anorexia Nervosa
Weight Fear Bothers Anorexics (four of these):
Weight below 85% of ideal body weight
Fear of fat
Body image distortion
Amenorrhea
For both bulimia and anorexia, the patient must
have all four criteria to merit the diagnosis.
Cognitive Disorders
Dementia
A memory impairment plus one of four BREW symptoms:
Memory BREW:
Memory impairment
Behavior disorganization (apraxia)
Recognition impairment (agnosia)
Executive functioning impairment
Word problems (aphasia)
Something is wrong with the memory brew of the patient
with dementia. A gradual onset of a memory problem is
required, but only one of the commonly associated symptoms
(BREW) must be present.
Delirium
Medical FRAT (all five of these):
Medical cause of cognitive impairment
Fluctuating course
Recent onset
Attention impairment
Thinking (cognitive) disturbance

Because delirium is caused by a medical illness, being

part of the medical fraternity helps to diagnose it. To
merit the diagnosis, all five criteria must be present.
Attention-Deficit Hyperactivity Disorder
There are 18 separate, though often redundant,
criteria for ADHD, making memorization impossible
for anyone without a photographic memory . As with
panic disorder, I suggest breaking the symptoms into
four broad categories, which can be remembered by
the mnemonic MOAT (you'll need a MOAT around the
classroom for the hyperactive child):
Movement excess (hyperactivity)
Organization problems (difficulty finishing tasks)
Attention problems
Talking impulsively
An excellent mnemonic for the major risk factors for suicide is SAD PERSONS.
Mnemonic: SAD PERSONS (risk factors for suicide):
Sex: Women are more likely to attempt suicide; men are more likely to succeed.
Age: Age falls into a bimodal distribution, with teenagers and the elderly at highest risk.
Depression: Fifteen percent of depressive patients die by suicide.
Previous attempt: Ten percent of those who have previously attempted suicide die by suicide.
Ethanol abuse: Fifteen percent of alcoholics commit suicide.
Rational thinking loss: Psychosis is a risk factor, and 10% of patients with chronic schizophrenia
die by suicide.
Social supports are lacking.
Organized plan: A well-formulated suicide plan is a red flag.
No spouse: Being divorced, separated, or widowed is a risk factor; having responsibility for
children is an important statistical protector against suicide.
Sickness: Chronic illness is a risk factor.

Although useful for determining a patient's long-term risk for committing suicide, these risk
factors are less useful for assessing imminent risk, and imminent risk is the most important
factor to assess during a diagnostic interview.

Contd..
Contd…
One study helpful in identifying risk factors for short-term risk
is the National Institute of Mental Health Collaborative
Depression Clinical Study (Clark and Fawcett 1992).
Researchers followed 954 patients with major affective
disorders and found that clinical features associated with
early suicide (i.e., within 1 year of assessment) included
Anxiety
Panic attacks
Anhedonia
Alcohol abuse
Clinical factors associated with a later attempt (at 5 years)
included
High levels of hopelessness
SI
History of suicide attempts
Personality Disorders: PARANOID
Mnemonic: SUSPECT (four of these seven)
Spousal infidelity suspected
Unforgiving (bears grudges)
Suspicious of others
Perceives attacks
Views everyone as either an Enemy or a friend
Confiding in others feared
Threats perceived in benign events
Personality Disorder: SCHIZOID
Mnemonic: DISTANT (four of these seven)
Detached (or flattened) affect
Indifferent to criticism or praise
Sexual experiences of little interest
Tasks (activities) performed solitarily
Absence of close friends
Neither desires nor enjoys close relations
Takes pleasure in few activities
Personality Disorder: SCHIZOTYPAL
Mnemonic: ME PECULIAR (five of these ten)
Magical thinking or odd beliefs
Experiences unusual perceptions
Paranoid ideation
Eccentric behavior or appearance
Constricted (or inappropriate) affect
Unusual (odd) thinking and speech
Lacks close friends
Ideas of reference
Anxiety in social situations
Rule out psychotic disorder and pervasive developmental
disorder
Personality Disorder: BORDERLINE
Mnemonic: I DESPAIRR
Identity disturbance.
Disordered, unstable affect owing to a marked reactivity of
mood.
Chronic feelings of Emptiness.
Recurrent Suicidal behavior, gestures, or threats, or self-
mutilating behavior.
Transient, stress-related Paranoid ideation or severe
dissociative symptoms.
Frantic efforts to avoid real or imagined Abandonment.
Impulsivity in at least two areas that is potentially self-
damaging.
A pattern of unstable and intense interpersonal
Relationships characterized by alternating extremes of
idealization and devaluation.
Personality Disorder: ANTISOCIAL
Mnemonic: CORRUPT (three of these seven)
Conformity to law lacking
Obligations ignored
Reckless disregard for safety of self or others
Remorse lacking
Underhanded (deceitful, lies, cons others)
Planning insufficient (impulsive)
Temper
Personality Disorder: HISTRIONIC
Mnemonic: PRAISE ME (five of these eight)
Provocative (or sexually seductive) behavior
Relationships (considered more intimate than they are)
Attention (uncomfortable when not the center of
attention)
Influenced easily
Style of speech (impressionistic, lacks detail)
Emotions (rapidly shifting and shallow)
Made up (physical appearance used to draw attention to
self)
Emotions exaggerated (theatrical)
Personality Disorder: NARCISSISTIC
Mnemonic: SPEEECIAL (five of these nine)
Special (believes he is special and unique)
Preoccupied with fantasies (e.g., of unlimited success,
power)
Envious
Entitlement
Excessive admiration required
Conceited
Interpersonal exploitation
Arrogant
Lacks empathy
Personality Disorder: AVOIDANT
Mnemonic: CRINGES (four of these seven)
Certainty of being liked required before willing to risk
involvement
Rejection possibility preoccupies his thoughts
Intimate relationships avoided
New relationships avoided
Gets around occupational activities that involve
interpersonal contact
Embarrassment potential prevents new activities
Self viewed as unappealing, inept, inferior
Personality Disorder: DEPENDENT
Mnemonic: RELIANCE (five of these eight)
Reassurance required for decisions
Expressing disagreement difficult (because of fear of loss
of support or approval)
Life responsibilities assumed by others
Initiating projects difficult
Alone (feels helpless and a sense of discomfort when
alone)
Nurturance (goes to excessive lengths to obtain nurturance
and support)
Companionship sought urgently when close relationship
ends
Exaggerated fears of being left to care for self
Personality Disorder: OBSESSIVE COMPULSIVE
Mnemonic: LAW FIRMS (four of these eight)
Loses point of activity
Ability to complete tasks compromised by
perfectionism
Worthless objects (unable to discard)
Friendships (and leisure activities) excluded (owing
to preoccupation with work)
Inflexible, scrupulous, overconscientious
Reluctant to delegate
Miserly
Stubborn
AXIS IV
The axis IV section is where you should note any psychosocial problems that may be aggravating
the psychiatric condition or, in some cases, may be the result of it. DSM-IV-TR groups these
problems into nine helpful categories:

Problems with primary support group

Problems related to the social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to health care services
Problems related to interaction with the legal system
Other psychosocial and environmental problems

Remember that some apparently positive events can contribute to psychiatric problems as well,
as in the example of the patient who finally gets a big promotion and develops panic disorder
related to fear of failure in the new position.
 GAF SCORE:

GAF score Applicable clinical situation

90 and above Probably none. Very few people with absent or minimal symptoms will make it into your office.

80 Patients who were once symptomatic but who have been successfully treated and are continuing to see you to maintain remission.

70 Mild depression, mild anxiety, mild problems functioning.

60 Moderate symptoms, moderate functioning problems.

50 Serious symptoms, serious functioning problems.

40 Severe symptoms. You will be considering hospitalization for patients with GAF of 40 or below.

30 and below Very severe symptoms. If this patient is not yet in the hospital, call an ambulance immediately.
DEFENCE MECHANISMS:

Mature defenses
   Suppression
   Altruism
   Sublimation
   Humor
Neurotic defenses
   Denial
   Repression
   Reaction formation
   Displacement
   Rationalization
Immature defenses
   Passive aggression
   Acting out
   Dissociation
   Projection
   Splitting (idealization/devaluation)
Psychotic defenses
   Denial of external reality
   Distortion of external reality