A Psychiatry CASC station on MedMock, start to finish
This is an illustrative Psychiatry CASC station written by MedMock to show what the station is like: the brief, everything the patient says, the candidate’s answers and the feedback were all written by us, not recorded from a real session. The feedback is laid out the way MedMock marks this exam. It is here to show the format and the standard, not as a model answer to learn by heart.
The brief
You are a core trainee in psychiatry in a community mental health team clinic. Ms Leah Turner, aged 27, has been referred by her GP because she washes her hands many times a day and the skin on her hands is cracked and sore. She lives with her boyfriend. Take a history to elicit the symptoms of her presenting complaint. Assess the impact of her symptoms on her life. Screen for associated psychiatric conditions and assess her risk. You are not expected to discuss treatment.
History‐taking (Presenting complaint): the full transcript
Hello, Ms Turner? I'm Dr Hughes, one of the psychiatry doctors. Thank you for coming in. Your GP has written to us about some difficulties with hand-washing. Could you tell me in your own words what's been happening?
It's so embarrassing. I wash my hands all the time. Look at them, they're cracked and they bleed. I know it's ridiculous, but I can't stop.
Thank you for telling me. I can see how much this is getting to you. When you feel you have to wash, what goes through your mind just before?
That there are germs on my hands, from door handles, bins, anything other people have touched. And that I'll pass them on to my mum and she'll get really ill. She's got a bad chest. It'd be my fault.
That sounds frightening. When that thought comes, does it feel like your own thought, or as if it's been put into your head from outside?
No, it's mine. It's my own brain doing it, that's the worst part. I know it's over the top.
What happens if you try to resist it and not wash?
I tell myself it's rubbish and try to distract myself, but the anxiety just builds and builds until I give in. Then I feel better, for about five minutes.
Could you talk me through the washing itself: how often, how you do it, and how much of your day it takes?
Thirty or forty times a day. It has to be the same every time: fingers, then palms, then up to my elbows, counting to twenty for each bit. If I lose count, I start again. Then I shower for an hour at night. Three or four hours a day altogether, more on a bad day.
Apart from washing, is there anything else you do to feel safe, like cleaning, avoiding things or asking others for reassurance?
I wipe everything down, my phone, my keys, the shopping. I won't use public toilets or get the bus. And I keep asking my boyfriend if I've washed properly. He's started washing with me, just to keep the peace.
It sounds as if it's affecting him too. When did all this begin?
I've always been a bit particular, since school. But it got really bad about a year ago, after Mum was in hospital with pneumonia. Now it's taking over everything. I'm late for work every day, I've been signed off for two weeks, and I've stopped seeing friends because I can't cope with being in their houses.
That's a lot to be carrying. With all of that going on, how has your mood been?
Low. I cry most days. I don't enjoy anything any more, and I'm not sleeping. I'm up till two because of the shower.
When people feel as low as that, they sometimes have thoughts that life isn't worth living, or of harming themselves. Have you had thoughts like that?
Sometimes I think it'd be easier if I just didn't wake up. But I'd never do anything. I couldn't do that to my mum.
Thank you for being honest with me. Have you ever made any plans to end your life, or harmed yourself in any way?
No, never. It's more that I'm exhausted by it all.
There are a few questions I ask everyone. Have you ever heard voices when no one else is around, or felt that someone else was controlling your thoughts? And do you drink or use anything to help you cope?
No, nothing like that. I'm not going mad, am I?
No, you're not. Almost everyone has unwanted thoughts like yours from time to time. What you're describing happens when they come very often and cause a lot of distress, and it's something we see a lot and can help with. I also asked about alcohol. Do you drink, or use anything else, to get through the day?
A glass of wine some evenings to calm down, that's all. No drugs.
Let me check I've understood. For about a year, and less severely before that, you've had unwanted thoughts that germs on your hands will make your mum ill. You know they're your own thoughts and you try to resist them, but the anxiety builds until you wash, and washing and cleaning only ease it for a short while. It takes three or four hours a day, you're off work, and your mood has been very low, with thoughts that it would be easier not to wake up, though you've never made plans or harmed yourself. What you're describing sounds like obsessive-compulsive disorder, or OCD. I'll talk it through with my consultant so that we can discuss the options with you. In the meantime, please see your GP about your hands. And if those thoughts about not waking up get stronger, or you feel you might act on them, get help straight away through your GP, NHS 111 or A&E. Have I missed anything?
No, that's it exactly. It's a relief to hear it's got a name. I honestly thought I was going mad.
Example feedback
90 / 100
5 of 5. Elicited the obsession (germs on her hands making her mother ill), checked it was her own thought and that she resists it, then the ritual, its rules and the three or four hours a day it takes, plus the cleaning, avoidance and reassurance-seeking around it.
4 of 5. Established the effect on work, friends and her boyfriend, the worsening after her mother's illness, low mood with loss of enjoyment and passive thoughts of death, then asked about plans and self-harm and screened for psychosis and alcohol. Previous episodes and treatment, tics and other related problems were not covered.
4 of 5. Warm and unhurried, and met "I'm not going mad, am I?" with "No, you're not. Almost everyone has unwanted thoughts like yours from time to time". One double question, on voices and on alcohol, left the alcohol question unanswered until it was asked again.
What went well
- Separated an obsession from thought insertion with one clear question: "does it feel like your own thought, or as if it's been put into your head from outside?"
- Looked beyond the washing to the behaviours that keep OCD going and the people drawn into it: "is there anything else you do to feel safe, like cleaning, avoiding things or asking others for reassurance?" brought out that her boyfriend now washes with her, which the candidate picked up ("It sounds as if it's affecting him too").
- Asked about suicide directly and in steps ("Have you ever made any plans to end your life, or harmed yourself in any way?"), safety-netted at the end, and did not forget her physical health: "please see your GP about your hands".
What to improve
- Complete the screen for associated conditions: ask briefly about tics and other obsessive-compulsive related problems, such as preoccupation with appearance, and whether she has had help or treatment for this before. Each would shape the plan your consultant makes.
- Ask one question at a time. "Have you ever heard voices when no one else is around, or felt that someone else was controlling your thoughts? And do you drink or use anything to help you cope?" joined two unrelated topics, and she answered only the first. The College's CASC feedback guidance lists multiple questions as a poor questioning style.
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