Courses and Mock Exams for MRCPsych CASC

Different courses offer unique features. The primary focus of CASC courses is the practice of different stations.  How the authors have organized them can differ; for example, whether candidates take turns completing stations or do complete circuits.  Psychiatrists from higher trainees to consultants staff these exams. Sometimes these might include college examiners themselves.  The role-players include those who have taken the exam themselves.

 

Communication-focused

You can best cover communication and clinical skills within local deanery-run MRCPsych courses. This includes CASC scenarios and can be helpful in the run-up to exams. This may help if communication skills at your medical institute, you did not learn communication skills or if English is not your first language.  

Private Courses

There are also several private providers that vary in terms of content, cost, and quality.  Some focus on communication skills (e.g. Oxford course), some courses contain actual CASC scenarios but with limited feedback (e.g., SPMM), and others offer individual practice stations via Skype with consultants, higher trainees, and CASC actors (e.g., Cognitions for CASC).

FCPS 2 October 2012

Q1. Parents bring a 24-year-old single man for showing violent and abusive behavior, self-muttering, inappropriate social behavior breaking into laughter one minute, and then crying incessantly for no obvious reason. They often see him gazing meaninglessly at objects and standing on one leg for an entire day. He has been ill for over three years continuously. They have treated him with haloperidol, olanzapine, and risperidone with no response to treatment. He has rapidly gained weight in the last few months and now weighs 110 kg. His height is 170 cm. 

1. What could be the most likely diagnosis?
2. What could be the reasons for the poor response to treatment? 
3. What is the likely pathophysiological basis of his rapid gain in weight
4. What will be the individual's BMI? 
5. What lab tests would you request in this case? 
6. In the light of current evidence, suggest therapeutic options that you may consider.

2 Read the following three clinical scenarios careful carefully and respond to queries.

1. A married father who was not agreeing to his demands for getting him married, had not been sleeping well for a week, purchased ten a dozen shirts in last two days, sold his taxi for two hundred thousand the greatest social worker of the world who had a mission to help and believed that he never felt so well ever in his life. He a truant thousand to help me given child.
2. A 38-year-old woman presented with restlessness, overactivity interfering behavior for the last two weeks. The psychiatrist for talk and seemed extra happy without an obvious reason. Previously she was the past five years to treat depression that she left a year ago.
3. A 20-year-old man has been experiencing repeated episodes of depressed mood associated with disturbed biological functions and episode overactivity, restlessness, and elation. The episodes have been occurring over the past five years, each episode lasting for a few days. No hi, any psychoactive substance abuse.

For each scenario, answer the following questions, separately. 

1. What is your provisional diagnosis for each scenario? 
2. What is the fundamental commonality between them?
3. Identify drug treatment for each? 
4. Identify the case with the worst and the one with the best prognosis, giving reasons for each.

Q.3 A 50-year-old married bank officer presents for the first time with features of acute anxiety including palpitations, excessive sweating giddiness, and fearfulness 

1. What medical causes would you consider in the differential diagnosis? 
2. How would you manage him if after a comprehensive evaluation you diagnose him as a case of panic disorder?

Q4 Miss X is a fourteen-year-old girl living in an orphanage. She finds it exceedingly difficult to sleep on account of nightmares and jumps in the chair when the doorbell rings. She complains of a persistent dull lower abdominal pain that does not respond to any painkiller. Allow and radiological/ultrasonographic investigations have been found normal, she has been a victim of regular physical and sexual abuse since the age of eight. 

1. What is the most likely diagnosis in this case? 
2. List the likely psychosocial difficulties and psychiatric she may develop in the years to come?
3. What are the various pharmacological and non-pharmacological interventions suitable for this patient?

Q5. 

1. What is the psychophysiology of antisocial personality disorder? 
2. What psychophysiological measures can we use in the assessment of antisocial personality disorder?

Q.6 A 35-year-old married homemaker with 4 children is being treated for a severe depressive episode for the last 3 months. She has shown little improvement with the trial of two antidepressants, escitalopram venlafaxine: 

1. How shall you assess this patient?
2. What are the distinct steps and options for pharmacological treatment in this case?

A 5-year-old child presents with behavioral problems at home, which include refusal to follow parental instruction and poor table manners. His teacher reports that he has difficulty getting along with friends and daydreams excessively. 

1. What is the differential diagnosis?
2. What will be the evaluation and management steps in this case?

A 3-year-old child is referred by the pediatrician to you for evaluation Parents who are going through a divorce after 4 years of unhappy marriage note that the child likes to stay by himself. The caregiver (Ayah) can communicate with the child, though his language is delayed (can speak only one or two words) and plays with only one toy, although he has many toys 

1. How will you evaluate this child? 
2. What are the most likely diagnosis and the list of differential diagnoses? 
3. How will you manage this case? 
4. What is the short- and long-term prognosis in this case?

His colleagues bring a 60-year-old man for making repeated mathematical errors in calculations, ignoring the entries of important financial documents, coming late to the office, and frequently spilling the tea on his clothes. a) What will be your provisional diagnosis and differential diagnosis? b) What specific physical and neurological and mental state signs would you look for? c) Name four laboratory and three radiological investigations you would consider while investigating this case?

 

Q.10 A relative of the patient who admitted the patient with the diagnosis of paranoid schizophrenia wants to take him home over the weekend. The patient is on a maintenance dose of a) Give the leave procedure in accordance with the Mental Health Ordinance 2001 b) The relative does not bring the patient from leaving on the agreed-upon date, how would you proceed according to the Mental Health Ordinance 2001?

11. A 56-year-old man is getting medication for diabetes mellitus, ischemic heart disease, and hypertension. He is currently admitted to the intensive care unit by a medical specialist on account of chronic renal failure. The nurse on duty tells the doctor that the old man gets irritable, talks irrelevantly, does not recognize anybody around and fears his caregivers and family members. These symptoms usually become worse at night. a) What is the most likely diagnosis in this case? b) What are the major causes of such a presentation? c) How will you manage this case?

12. A 52-year-old lady is referred by a general physician with the complaint of abnormal movements around the mouth and some abnormal hand movements. The patient was treated by a psychiatrist 02 years back but never revisited the psychiatrist and continued the treatment on her own.

1.  What differential diagnosis would you consider?
2. What treatment options are available? 

During a TV interview, they stated that patients with schizophrenia are more likely to be violent than the general population. How would you respond to inform the general population and compare it with patients with other mental illnesses focusing on the predictors of violence?

 Q13: A 35-year-old male patient, suffering from bipolar affective disorder, is on lithium carbonate for the last 10 years. He was stable till 6 months ago but since then has increased frequency and severity of episodes despite good compliance and consistent maintenance of lithium blood levels.

Q 14.  

1. What do you think maybe the mechanism for this unresponsiveness to lithium
2. How would you manage this unresponsiveness to lithium? 
3. Lithium is relatively less effective, with an efficacy rate of around 30 percent in which six conditions?

15 A recent trial on the effectiveness of typical versus atypical antipsychotics included that there is no difference between the two groups Critically evaluate this statement in the light of recent advances, naming few studies with similar results and findings.

16 A young lady of 28 came to psychiatric OPD with an irresistible urge to over at followed by feelings of guilt and self-induced vomiting. She also uses laxatives to compensate for overeating. She wants to know if this is a normal pattern of behavior or an illness? 

1. How you will respond to her?
2. What do you think is the most likely diagnosis? 
3. Outline management steps for this patient according to the NICE 2004 stepped-care approach

17.  A chain smoker for the last 25 years has recently been diagnosed with severe ischemic heart disease. His physician advises him to quit smoking, but he is convinced that smoking has nothing to do with his health. His wife believes that he is dependent on cigarettes and it is difficult for him to quit. Respond to the following queries made by her 

1. What are the psychophysiological effects of nicotine? 
2. How would you manage nicotine dependence in this case? 
3. Is this a psychiatric disorder? If yes, what is it called in ICD-10 and what are the diagnostic guidelines?

Q.18 A 20-year-old male from Waziristan is brought to the Psychiatric Intensive Care Unit for an urgent psychiatric consultation after being arrested by agencies. He attempted to blow himself with a bomb and made a physical assault on a quad at a check post. He remains abusive and threatens to kill all "enemies of Islam, wears when approached and thinks that he will blow himself up with a bomb to attain access to 'heaven and other bounties" promised to him by his teachers 

1. Keeping in mind the risk factors for violent and suicidal behavior and the sociocultural context of the individual, list ten questions that you will ask from the individual and the representatives of agencies to establish the abnormality/psychiatric disorder in the individual. 
2. If the individual does not fulfill any criteria of a formal mental illness, how would you respond to a query by a media representative asking if the individual is mentally ill and "insane"?

Q.19 Mrs. X is a 26-year-old known patient of bipolar affective disorder type 1 She is being treated with Valproic Acid and lithium carbonate. She now plans to conceive. She seeks your advice on the relative advantages and disadvantages of conceiving and using lithium during pregnancy. How would you respond to the following queries of the patient? 

1. What are the risks if I stop all treatment during pregnancy? 
2. What advice will you give? Illustrate your response with references from literature?
3. What risks do I run if I continue to use lithium during pregnancy?
4. What impact can lithium have if I will breastfeed my baby?

Q.20 A34-year-old operating room assistant has been referred to you by a physician to whom he reported 9th time in the last three months with a fear that he has developed AIDS, requesting to examine him and re-testing him for AIDS. He reveals that his roommate in the mess recently revealed himself to have homosexual relationships with multiple partners. The client himself never had a homosexual contact nor carries a factor for AIDS. He has anankastic-traits. He remains worried about his health however has no depression or disturbed biological functions. a) What will be the differential diagnosis in this case? What is the most likely diagnosis? Justify. b) How would you manage this case?

General Advice for Written Papers (MRCPsych Paper A and B)

We need preparation for the written exams, and we would suggest you think about starting your revision at least three months before each one. Although it’s difficult to balance examination revision with a full-time job, it is possible with wonderful organisation and discipline. Furthermore, many people have other responsibilities, such as children, which makes it much more difficult to fit in. It may have been years since you took your medical school examinations, and getting back into the swing of things can take some time. One technique is to start with half a day on weekends or a couple of evenings each week, then escalate the time as the examination approaches. There will be times when you can’t do any revision, for example, during weeks of night shifts. Although individuals strive to cram as much studying as possible into the weeks leading up to the test, it is equally crucial to relax and enjoy yourself. Rather than making your preparation less time-effective, scheduling some relaxation time will make your revision period more productive.

 

A good first step would be to study the Royal College of Psychiatrists’ examination web pages. There are details of the syllabus, regulations, frequently asked questions, and lots more useful bits and pieces. Google’ MRCPsych examinations’ to find the official College website.

 

Regarding what to revise, make sure you look carefully at the syllabus for each examination on the Royal College website to check the areas you need to cover in your revision. There is no point in covering areas that don’t appear in the examination, and you would better spend your time learning things. Although the proportion of questions in each subject area is worth bearing in mind, it isn’t the only factor. It would likely be better to allocate your time to concentrate on the areas you find most challenging.

 

The biggest change in the written exams has been moving from 3 written papers to 2. There are now 2 written exams, papers A and B, each comprising 200 questions over three hours. The exams contain multiple-choice questions (MCQs) and extended matching items (EMIs), with a rough split of 2/3 MCQs and 1/3 EMIs.

Examination online sites from the Royal College of Psychiatrists are a fantastic place to start. There are syllabus details, restrictions, frequently asked questions, and a slew of other valuable information. The official College website may be found by searching for "MRCPsych exams."

The CASC

CASC is an OSCE-style clinical exam made up of 16 stations in total. There is one circuit of eight stations in the morning and one circuit of eight stations in the afternoon. They have scrapped previously linked stations.  Any clinical topic can come up, and only the most impractical scenarios are off-limits. Commonly tested stations include:

• Brief history-taking e.g. psychosis, depression
• Collateral history e.g. in dementia
• Risk assessment following self-harm information-giving e.g. ECT, medication, psychological therapies
• Discuss management plans with consultants and other members of staff, e.g. nursing students and ward managers.
• Physical examination e.g., EPSEs, cardiovascular, neurological

The CASC tests knowledge and communications skills such as history taking, explanation & advice, breaking bad news, and managing challenging consultations.

When you first look into the CASC exam, the pass rate may not fill you with optimism about passing it. However, having a rough idea of what the CASC involves at the start of your training and looking at the requirements in more detail when you are preparing for the papers is a good idea. When studying for the written papers, start thinking about how you would make history for the topics you are preparing and read the relevant leaflets for patients - imagine you are explaining it to a patient or relative. It may even make revising for the written papers less abstract!!

Speak to trainees who have sat the CASC. There is also information available online about past stations. You will need to train your body to recognize what seven minutes feels like - timed practice as early as possible is very important. Mock exams are a good way to prepare for the range of skills you have to show in a short time and also develop the ability to quickly change from one task to another. There are ‘OSCE timers’ apps available that have a one-minute warning bell and an ‘end of examination’ prompt which creates the right amount of anxiety/anticipation to prepare you for the big day.

Practical issues during the exam

You get a short time before each station. There is no defined way to use it this time, but make sure you use it! You may decide to take notes but don’t let this distract you from thinking about the question. You may just want to write the name of the patient and the key task that they have asked you to undertake, and a few areas you’d like to cover. You can also take notes during the first stations of each linked pair details will stick in your mind and they will give you another task with some information for the linked station. Taking notes can be a welcome distraction to the station, and you won’t be as present in the station.

The UK sitting of the CASC takes place at the English Institute of Sport in Sheffield. They hold it in a sizeable room with several circuits going on at once. Noise carries, and this includes the examiners and role-players talking to each other between candidates. Listen, but it might not always be positive comments and may derail you if things have not gone, and you thought. Remember, it’s only the opinions of people who have seen you for a few minutes in an already stressful setting.

There are no rest stations on the circuits, but you potentially have several hours to wait between the morning and afternoon sessions. There is enough time to have an excellent lunch and get focussed on the afternoon (though don’t rely on the café in the venue being open) Some people like to talk through the stations they have just sat with friends, others might find this frustrating and unhelpful Remember, there is nothing you can do to change things and you need to focus instead on the afternoon stations. What has gone on, however, may also highlight things you have missed out on which can then be remembered for the second circuit?

During each station, let the role-player set the initial agenda but make sure you steer things in the right direction later on if needed. Summarising is useful to double-check information and re-focus the interview. Listen for cues and address anxieties when they appear. Don’t be afraid to answer questions, even if the answer might not be something the patient might want to hear—this may be the only way to move on. Be careful not to ask double questions—the actor might only answer one part.

Books we found helpful for CASC

‘Pass the CASC’

CASC books are far from perfect. One of the most popular is ‘Pass the CASC’ by Dr. Seshni Moodliar. This has a list of all the stations that have previously come up and is a good way to map out your revision. The content is comprehensive, but some phrases suggested in the book have not served candidates well.

Psychiatry: Breaking the ICE Introductions, Common Tasks, Emergencies for Trainees

Although not written for the MRCPsych exam, "Psychiatry: Breaking the ICE Introductions, Common Tasks, Emergencies for Trainees" by Sarah Stringer is an excellent all-rounder book. It’s a practical guide to working as a psychiatry trainee and covers all commonly encountered situations. Many of these give good advice that would help in passing CASC.

The Maudsley Handbook of Practical Psychiatry 

The Maudsley Handbook of Practical Psychiatry has a section on special interview situations. This has some excellent advice about how to manage challenging situations.

Preparing for CASC:

Have a plan and stick to it. Plan out each day where you work through a list of previous stations together. Find someone you want to spend the day with and practice regularly. Make it fun and schedule in breaks. Be honest with each other when giving feedback. Check that your practice is going in the right direction by asking trainees who have passed the CASC for feedback. Many trainees find that organizing a small group of three to four trainees who are all about to sit CASC and meet regularly to go through stations, practice your approach, and learn from each other can be a great way to prepare. If you are in a more rural location and struggle to meet up, consider regular Skype meet-ups instead.