CASC · Brain Map

CASC Brain Map: Last Minute Revision

MRCPsych CASC exam — a complete, free guide to the different exam themes you need to revise when the exam is coming soon.

General Adult Psychiatry

Older Adults

Child and Adolescent Psychiatry

Learning Disability Psychiatry

Forensic Psychiatry

Addiction Psychiatry

Psychotherapy

Eating Disorder Psychiatry

Perinatal Psychiatry

CASC

MRCPsych CASC

Stations, discussions & explanations

General Adult Psychiatry

Eliciting psychotic phenomenology

60-Second Summary

The marks are in the form of the experience, not the story about it. Systematise one belief properly and you have passed.

In the Room

Suspicious patients close down if you interrogate before you reassure. Explain why you are asking before you ask.

Spot It

Read the task boundary first. Some stations restrict you to eliciting first-rank symptoms only, no risk, no differential. Wandering outside it loses more marks than it gains.
The referral says 'not eating' or 'headache'. The psychosis is underneath, and only surfaces if you let the patient talk before you start directing.
Delusional perception is the single highest-value item and almost nobody elicits it: a real percept followed instantly by an unrelated delusional meaning.

Must Cover

Let them speak freely for the first 60–90 seconds. Directed questioning too early buries the psychopathology you need.
Auditory hallucinations in full: onset, frequency, second vs third person, running commentary, thought echo, content, whose voice, and whether they hear it now.
Screen every other modality: visual, olfactory, gustatory, tactile, somatic. Saying what is absent scores; thinking it does not.
Systematise the delusion: content, onset, conviction, fixity, how they explain it, how far it extends, what they have done about it.
Thought alienation: insertion, withdrawal, broadcast. Ask them plainly, in their own words.
Passivity: made thoughts, made feelings, made actions, somatic passivity.
Delusional perception: 'at the moment you saw that, what went through your mind?' Name it if you find it.
Test conviction gently once, to separate delusion from overvalued idea. Do not argue.
Mood screen, brief substance screen (type, amount, chronology relative to onset), insight.
Never use 'hallucinations' or 'delusions' with the patient.

Ask It Like This

"Do the voices talk to you, or about you to each other?"
"Can you hear them right now, sitting here with me?"
"When you saw the man in the blue jacket, what went through your mind at that moment?"
"Is anything else going on that's been hard to explain to people?"
"Was there anything that helped you cope?" This opens substance use without confrontation.

Risk

Self-neglect first: food, fluid, hygiene. This is often the main risk, not suicide.
Suicide, and harm to others through delusional content: who, specifically, and what have they done so far.
Command hallucinations, passivity, and absent insight are the three features that raise concern most.
From others: exploitation, including by dealers.

Example Stations Covering This Theme

Delusions, Psychosis MSE, First-Rank Symptoms, Psychosis Collateral History, Early-Onset Psychosis.

Explaining psychosis and antipsychotics to a family

60-Second Summary

An angry relative who feels kept in the dark. Let them vent, then explain in their words, not yours.

In the Room

Never become defensive. Anger in these stations is fear, and it is the examiner's main test.

Spot It

They arrive with a wrong model: 'it's just depression', 'he'll be a zombie', 'he's dangerous'. Correct each one directly rather than talking past it.
They usually bring a written list of questions. Reserve the last two minutes for it or you will run out.
Clozapine stations are not a blood-monitoring monologue. Constipation and infection vigilance carry equal weight.

Must Cover

Ask what they already understand, and what they most want from the meeting, before you explain anything.
Psychosis vs schizophrenia: psychosis is a symptom set occurring across several illnesses; schizophrenia is one diagnosis.
Positive symptoms vs negative symptoms; negative symptoms often come first and can look exactly like depression.
Genetic plus environmental causes: trauma, stress, cannabis. No single cause, and not their fault.
Clozapine: reserved after two failed antipsychotics; common effects settle (sedation, hypersalivation, dizziness, tachycardia, constipation); rare serious ones are agranulocytosis, myocarditis, seizures, bowel obstruction; FBC weekly ×18 weeks, then fortnightly to 52 weeks, then monthly; no depot form exists.
Clozapine constipation is potentially fatal and under-recognised. Say so explicitly.
Depot: same drug, same risks as the oral form, given intramuscularly for steady release; test dose first; drawbacks are injection discomfort and site infection.
Course is variable: recovery, relapsing-remitting, or persistent. Do not promise either outcome.
Chunk and check. Ask them to say it back, framed as checking you explained it well.
Close with written information, a named contact, and a follow-up meeting.

Ask It Like This

"Before I start, what's your understanding of what's happened so far?"
"What's worrying you most about all this?"
"I've given you a lot there. Can I check what you've taken from it?"
"You mentioned you'd heard it turns people into zombies. Can I take that one head on?"

Risk

Ask what they have seen at home: self-neglect, threats, absconding. The relative often holds the risk history.
If admission or detention is likely, say so now and explain it as protective, with a right of appeal.
Carer strain: ask how they themselves are coping.

Example Stations Covering This Theme

Schizophrenia Explanation, Clozapine Explanation, Long-Acting Injectable Explanation, Early-Onset Psychosis Management.

Antipsychotic side effects and physical health monitoring

60-Second Summary

The side effect is the presenting problem. Recognise it, name it, and change the plan; do not defend the prescription.

In the Room

Do not try to talk them into staying on the drug. Collaborate, and the marks follow.

Spot It

Always timeline the symptom against the drug or dose change. That single question makes the diagnosis in every one of these stations.
In akathisia, the suicidal ideation belongs to the akathisia. Missing that link is the classic fail.
Stopping smoking raises clozapine levels sharply. Miss this in the metabolic station and you can fail it.

Must Cover

Akathisia: objective restlessness plus subjective inner tension, worst in the legs. Ask them to stand still. Do not mistake it for anxiety or relapse.
Akathisia options: reduce dose, switch agent, or add propranolol or mirtazapine.
EPSE: distinguish acute dystonia, parkinsonism, akathisia and tardive dyskinesia. Examine: tremor on paper, cogwheeling, hypomimia, tongue, arm-drop, gait and arm swing.
NMS: rigidity, fever, autonomic instability, altered mental state, raised CK. Stop the drug, supportive care, urgent medical transfer; dantrolene or bromocriptine if severe. Differentials are sepsis and serotonin syndrome.
Prolactin risk by drug: very low (aripiprazole, clozapine, quetiapine, lurasidone) → low (olanzapine) → moderate (haloperidol) → high (risperidone, amisulpride, paliperidone, sulpiride).
Hyperprolactinaemia symptoms: oligo/amenorrhoea, low libido, galactorrhoea, infertility; in men gynaecomastia and low ejaculate volume. Exclude pregnancy, PCOS, hypothyroidism, prolactinoma.
Prolactin management ladder: monitor if asymptomatic and capacitous (warn re bone density) → dose reduction or switch → adjunctive low-dose aripiprazole.
Metabolic: elicit every cardiac risk factor, and monitor BP, HbA1c, lipids, weight. You are often the only doctor checking these.
Offer smoking cessation, but warn about the clozapine interaction in the same breath.
Normalise these effects as common and treatable, and show you are willing to change the plan today.

Ask It Like This

"When did this start, compared with the medication change?"
"Can you stand still for me for a moment?" This is the akathisia test.
"Has the restlessness ever made you feel life isn't worth living?"
"Would it be alright if we looked at your physical health today as well?"

Risk

Akathisia drives both suicide and non-adherence. Ask about both.
NMS is potentially fatal untreated: say the word 'emergency'.
Untreated hyperprolactinaemia risks osteoporosis; untreated metabolic syndrome is the mortality gap.
In every one of these, ask whether they have stopped the medication themselves.

Example Stations Covering This Theme

Akathisia, Extrapyramidal Side Effects, Neuroleptic malignant syndrome, Hyperprolactinaemia, Metabolic monitoring.

Depression: assessment and complex presentations

60-Second Summary

Get the syndrome, then ask the one extra question that changes the diagnosis: psychotic features, past mania, or a physical illness.

In the Room

With a retarded or stuporose patient, long silences are the station. Do not fill them with more questions.

Spot It

In psychotic depression the patient may not speak for the first minute or two. That is scripted. Wait, and keep encouraging.
In the collateral station the father died by suicide. That family history is the buried risk factor.
Post-MI and older-adult depression follow different treatment logic from standard depression: know that before you plan.
Nihilistic and Cotard's delusions explain the reduced oral intake. Link them explicitly.

Must Cover

Core syndrome: low mood, anhedonia, anergia, then biological (early waking, appetite, weight, libido, diurnal variation, psychomotor change) and cognitive (guilt, worthlessness, hopelessness, concentration).
Always screen for a past manic or hypomanic episode. It changes everything about management.
Psychotic features: delusions of guilt, poverty, illness, nihilism, Cotard's; mood-congruent hallucinations. Ask directly.
Treatment resistance means two adequate trials at adequate dose, duration and adherence: confirm all three before accepting the label.
TRD options: lithium augmentation, antipsychotic augmentation, venlafaxine or SSRI plus mirtazapine, ECT.
Post-MI: SSRI first line, avoid citalopram for QTc, watch SSRI-plus-aspirin bleeding risk; mild cases get guided self-help, moderate-severe get CBT or IPT.
Say the diagnosis out loud, including the qualifier: 'severe depressive episode with psychotic features'.
Screen alcohol and substances as both cause and consequence.
Instil hope. Depression, even resistant depression, has many remaining options.

Ask It Like This

"Have there ever been times when the opposite happened, when you had far more energy than usual?"
"Have you had any thoughts that things have gone badly wrong inside your body?"
"How much have you managed to eat and drink in the last few days?"
"Has anyone in the family struggled with their mental health, or taken their own life?"

Risk

Suicide, always, and in psychotic and older-adult depression, self-neglect and poor oral intake are the more urgent risk.
Family history of completed suicide is a static risk factor that candidates routinely miss.
Hopelessness and helplessness predict better than stated intent. Ask about them specifically.
In severe cases consider whether they can be kept safe at home tonight.

Example Stations Covering This Theme

Depression Collateral, Psychotic Depression, Treatment-Resistant Depression, Depression Post-MI, Psychotic Depression (older adult).

Explaining physical treatments for mood disorder

60-Second Summary

Learnable scripts. Rehearse them cold, personalise them to the person in front of you, and leave room for their list.

In the Room

Balance normalising the treatment against validating the fear. Do both, in that order.

Spot It

ECT stations are usually about a frightened relative and a patient who lacks capacity. The empathy is worth as much as the facts.
Lithium in a man of reproductive age still needs the pregnancy conversation, about his partner.
The sexual side effects station looks like management but is marked as communication.

Must Cover

Lithium indications: bipolar prophylaxis, TRD augmentation. Slow onset, and stopping it raises relapse risk: a real commitment.
Lithium early effects (fine tremor, thirst, polyuria, weight gain, metallic taste, often settling) vs long-term risks (renal, thyroid, parathyroid). Renal is the main irreversible one.
Lithium toxicity: GI symptoms first (nausea, vomiting, diarrhoea), then neurological (coarse tremor, ataxia, confusion, coma). An emergency. Interactions with ACE inhibitors, thiazides, NSAIDs; dehydration raises levels.
Lithium monitoring: baseline FBC, U&E, TFT, ECG; weekly levels while titrating; then levels 3-monthly, TFT and U&E 6-monthly.
Lithium in pregnancy: historic Ebstein's anomaly link (~1 in 1,000) not confirmed by recent studies, so present it as evolving. Levels fall as pregnancy progresses then rise peripartum. Breastfeeding not recommended.
ECT: for life-threatening depression or treatment failure; 6–12 sessions, twice weekly; general anaesthetic plus muscle relaxant, brief seizure, painless.
ECT risks honestly: anaesthetic mortality ~1 in 100,000; transient confusion, headache, amnesia around treatment; longer-term autobiographical memory effects that vary between people. Do not minimise.
Sexual side effects: assess libido, arousal and orgasm separately; distinguish baseline, depressed and on-treatment function; screen other causes before blaming the drug. Options are dose reduction, switch, or add-on.
Offer written information and a follow-up appointment every time.
If you do not know something, say so and offer to find out. Bluffing is more damaging than the gap.

Ask It Like This

"What have you heard about it already? I'd like to start from there."
"There's quite a lot to cover, so shall I go through it in stages and stop for questions?"
"Some people notice changes in their sex life on these tablets. Has that been the case for you?"
"You had a list of questions, shall we go through them now?"

Risk

Untreated: for lithium, relapse; for ECT, death from dehydration or suicide. Name the risk of not treating, not just of treating.
Toxicity and pregnancy planning are the two lithium safety items.
Sexual side effects drive covert non-adherence: ask whether they have already stopped.

Example Stations Covering This Theme

Lithium, ECT, Sexual Side Effects, Lithium in Pregnancy.

Mania and elevated mood

60-Second Summary

A disorganised, overfamiliar patient and too little time. Prioritise ruthlessly and stay boundaried.

In the Room

If they are overfamiliar, stay professional and reset the boundary politely. If they become irritable, de-escalate rather than push.

Spot It

In the older adult, ask what medication is new. Steroids precipitate mania and that is the whole station.
Grandiosity often shades into persecutory or erotomanic belief: follow it, because that is where the risk lives.
Someone has usually stopped their lithium. Find out when.

Must Cover

Core features: elevated or irritable mood, increased energy and activity, pressured speech, reduced need for sleep, distractibility, grandiosity, disinhibition, recklessness. One week for mania.
Directly ask about delusions and hallucinations. Candidates assume mania and forget to screen psychosis.
Sleep, appetite, weight and libido: the biological changes are quick marks.
Past psychiatric history, family history, and adherence: all three, briefly.
Organic and drug causes: steroids, stimulants, hyperthyroidism, frontal lesion, delirium, dementia. Screen in older or first-onset patients.
Functional impact: spending, work, school, relationships.
Redirect firmly but warmly. Short, clear, closed questions work better than open ones here.

Ask It Like This

"How much sleep have you needed lately, and do you feel tired?"
"Has anything changed with your medication recently, including anything from your GP?"
"Have you had any experiences lately that other people found hard to believe?"
"I want to make sure I understand, can I bring us back to that for a moment?"

Risk

Financial and sexual exploitation, and reckless spending: specific, and commonly the highest risk present.
Harm to others through irritability, and harm from others through disinhibition.
Self-neglect, dehydration and weight loss in prolonged mania.
Ask about driving and about substances.

Example Stations Covering This Theme

Mania MSE, Mania (older adult), Mania (adolescent).

The anxiety spectrum and obsessional disorders

60-Second Summary

Find one anxiety disorder, then screen for the rest: they cluster, and the screening is where the marks are.

In the Room

Normalise the embarrassment before you ask the detail. These patients have usually been dismissed before.

Spot It

These are diagnosis stations more often than management stations. Read the instruction and do not launch into treatment uninvited.
In hypochondriasis and BDD, test the strength of belief. Flexibility means it is not delusional: say so.
PTSD: gauge trauma severity gently. You are not there to re-traumatise.
Alcohol is the self-medication running underneath most of these.

Must Cover

Panic: discrete unpredictable attacks, autonomic symptoms, catastrophic cognitions about dying or going mad, avoidance, impact.
Agoraphobia: fear of public places or being trapped, with panic features; ask what they can no longer do, such as shopping, laundry, worship.
OCD: obsessions are intrusive, unwanted and recognised as their own; compulsions relieve anxiety short-term and maintain it long-term. ERP is the psychological mainstay, SSRI the pharmacological one, combined is NICE-recommended.
SSRIs are not addictive but do cause a discontinuation syndrome: taper slowly. Say both halves.
BDD: perceived defect, checking, camouflaging, repeated cosmetic requests. Do not confirm the defect is real.
Hypochondriasis: link onset to a trigger such as bereavement; explain misinterpreted bodily sensations and the worry–checking–reassurance cycle; more tests will not help.
PTSD (TRAVEL): Trauma, Reliving, Avoidance, Vigilance, Emotional numbing, Length (onset within a month, persisting beyond a month).
Screen the other anxiety disorders, plus mood and psychosis, in every one of these.
Ask about functional impact and time consumed: that is what makes it a disorder.

Ask It Like This

"When you're at your worst, what's the frightening thought that goes through your mind?"
"How much of your day does this take up altogether?"
"Do the thoughts feel like your own, even though you don't want them?"
"Some people find a drink takes the edge off. Has that been true for you?"

Risk

Self-neglect in agoraphobia: are they eating, washing, keeping the house safe.
BDD carries specific risks: self-harm, and unregulated or do-it-yourself cosmetic 'fixes'.
OCD: distress and guilt about the content of intrusive thoughts can be genuinely suicidal. Actual risk to others is very low.
PTSD: ask directly about access to firearms in military cases.

Example Stations Covering This Theme

Panic, Agoraphobia, OCD, Body Dysmorphic Disorder, Hypochondriasis, PTSD.

Self-harm, overdose and suicide risk

60-Second Summary

Before, during, after. Get the narrative first, then clarify: a tick-box risk assessment reads as one and is marked as one.

In the Room

Never criticise and never over-reassure. Acknowledge the disclosure and move on: that is what non-judgemental looks like under observation.

Spot It

The high-risk features are planning, final acts, precautions against discovery, high perceived lethality, and regret at surviving. Name them as you find them.
Some of these are deliberately diagnostically ambiguous. Tolerate the uncertainty: the task is the risk assessment, not the label.
In the self-discharge station, risk to the children is buried in his 'last chance' language. Ask about it.
In EUPD, the instruction says the risk assessment is brief. Believe it and spend your time on the personality features.

Must Cover

Before: precipitant, planned or impulsive, how the means were obtained, note or will, alcohol or drugs, who knew.
During: what and how much, where, alone, what they expected to happen, steps taken to avoid being found.
After: how they were found, did they seek help, how do they feel about surviving, what has changed, do they regret it.
Now: ongoing ideation, current plan, continued access to means, hopelessness, what they would do if discharged today.
Static factors: previous attempts, family history of suicide, male sex, physical illness, recent loss, forensic history.
Protective factors, asked explicitly: children, relationships, faith, engagement, ambivalence. Their absence is itself a finding.
Screen the underlying disorder briefly: depression, psychosis, substance use, EUPD.
EUPD features: affective instability, unstable relationships, disturbed self-image, impulsivity, abandonment fears, chronic emptiness, anger, transient psychotic or dissociative symptoms.
Adolescents: bullying, school, safeguarding, and always consider gathering collateral.
If you must decide disposal, state your formulation first, then the plan that follows from it.

Ask It Like This

"Take me through the day, from when you woke up."
"What did you think would happen after you took them?"
"How do you feel now, about the fact that you're still here?"
"What would need to be different for you to feel safe going home tonight?"
"Is there anything that stops you, anyone or anything you'd be leaving behind?"

Risk

Say the level out loud (high, moderate or low) and give the two or three features that drive it.
Alcohol both raises impulsive risk and is a treatment target. Make that point.
Ask about risk to others, including children and ex-partners. Candidates skip this in suicide stations.
If they want to leave, assess capacity to weigh the risk of leaving before you consider detention.

Example Stations Covering This Theme

Suicide Risk (impulsive), Overdose Risk, Suicide Risk (planned), Request to Self-Discharge, EUPD, Adolescent Overdose.

Neuropsychiatry and functional presentations

60-Second Summary

Precision about the sequence (aura, event, recovery) is what separates these from vague histories.

In the Room

Slow down in breaking bad news. There is far more time than it feels like, and silence is being marked.

Spot It

Never say 'pseudoseizures'. Use functional, dissociative, or non-epileptic. Your language choice is itself marked.
In TBI, grade severity by duration of loss of consciousness and post-traumatic amnesia before you discuss sequelae.
Missed alcohol history in a trauma patient is the classic trap: delirium tremens arrives around day three.
Breaking bad news is a communication station wearing a neurology costume. Do not over-explain the tumour.

Must Cover

TBI: LOC minutes = mild, days to weeks = severe. Then cognitive deficits, affective change, frontal personality change, psychosis risk, and functional impact. Early imaging can miss diffuse axonal injury.
TBI differentials: post-operative delirium, delirium tremens, pre-existing psychiatric illness.
Temporal lobe epilepsy: aura (epigastric rising, unusual smell, déjà vu, derealisation, fear), the witnessed ictal event, automatisms, post-ictal confusion and amnesia, precipitants, febrile convulsions, family history. Then EEG, MRI and bloods.
Non-epileptic seizures: real seizures with a psychological rather than electrical cause, arising outside conscious awareness, not put on. Use a mind–body example. CBT is the mainstay; prognosis is better with early diagnosis and acceptance.
Functional weakness: Hoover's sign, involuntary extension of the 'weak' leg when the good hip is flexed against resistance.
Dissociative presentations: look for la belle indifférence, a recent stressor, and secondary gain, and still screen mood and risk.
Breaking bad news (SPIKES): Setting, Perceptions, Invitation, Knowledge, Emotions, Summary. Warn before you deliver. Pause afterwards.
Avoid false promises. 'Most meningiomas are benign and slow-growing' is honest; 'this will be fine' is not.
Keep the patient central to decisions unless they lack capacity.

Ask It Like This

"What's the very first thing you notice, before anyone else would know something was happening?"
"Is there anyone who's seen one of these episodes who could tell me what they saw?"
"How much do you want me to tell you today? Some people want everything, some prefer the headline."
"I'm afraid I have some difficult news about the scan."

Risk

Driving: in epilepsy, TBI and functional seizures alike. Raise it.
Frontal disinhibition after TBI creates risk to others; ask the relative about aggression and judgement.
Screen mood and suicide in every functional presentation. These patients are often dismissed and often depressed.
Delirium tremens and Wernicke's if alcohol is in the picture: thiamine before glucose.

Example Stations Covering This Theme

Traumatic Brain Injury, Non-Epileptic Seizures, Temporal Lobe Epilepsy, Breaking Bad News, Fundoscopy (dissociative visual loss), Hoover's sign.

Capacity, identity and adult neurodevelopment

60-Second Summary

Three stations where the marks are for not presuming: not presuming incapacity, not pathologising identity, not dismissing lifelong symptoms.

In the Room

Curiosity, not persuasion. The moment you start arguing them into treatment you have left the marking sheet.

Spot It

Capacity is presumed. An unwise decision is not an incapacitous one. Do not try to persuade them round.
Gender incongruence is not a mental illness in ICD-11. Ask for name and pronouns and use them throughout.
Good concentration on video games does not argue against ADHD. Ask about tasks they find boring.

Must Cover

Capacity is decision-specific and time-specific, and requires an impairment of mind or brain.
The four limbs: understand, retain, weigh, communicate. Test each one out loud, and test understanding robustly without minimising the risk.
Explain the consequences of refusal plainly: for insulin, that means vascular complications, coma and death.
Gender incongruence: duration and impact, what the person actually wants, outline knowledge of hormone therapy and surgical options, support groups, and legal protection under the Equality Act 2010.
Screen and exclude psychosis, OCD and BDD as mimics, and screen comorbid anxiety and depression.
Adult ADHD: childhood inattention, impulsivity and hyperactivity, plus the adult form: procrastination, poor planning, interrupting, restlessness, boredom.
ADHD differentials: ASD, learning difficulty, conduct problems, mood disorder, substance use.
Cover every domain briefly rather than one domain thoroughly. Breadth scores here.
Conclude, and tell the person your conclusion. A capacity assessment that never states its answer scores badly.

Ask It Like This

"Can you tell me back in your own words what happens if you don't have the insulin?"
"What name and pronouns would you like me to use?"
"How long can you stick with something you find boring before your mind wanders?"
"I want to be clear: this is your decision. I'm here to make sure you have what you need to make it."

Risk

In capacity stations, the risk is the consequence of the refused treatment. Quantify it.
Gender incongruence: self-harm including genital self-harm, do-it-yourself surgery, suicide, and a raised rate of victimisation. Ask about safe sexual practice.
ADHD: impulsivity-related risk, including driving, substances, accidents, debt, offending.

Example Stations Covering This Theme

Capacity to Refuse Insulin, Gender Incongruence, Adult ADHD.

Physical examination stations

60-Second Summary

Sequence beats interpretation. Show your working, narrate it, and offer to complete.

In the Room

Dignity, exposure and chaperone are marked. So is thanking them and covering them up at the end.

Spot It

The opening is worth real marks: hygiene, introduction, identity, consent, chaperone, exposure, and asking about pain before you touch.
Every examination station has a psychiatric reason for being there. Name it: clozapine constipation, lithium hypothyroidism, antipsychotic pneumonia risk, alcohol and the cerebellum.
Narrate as you go unless told otherwise. If the instruction says explain to the examiner, that is half the marks.

Must Cover

Frontal: smell, personality change, proverbs, cognitive estimates, similarities, verbal fluency (letter S, one minute, no proper nouns), Luria three-step, go-no-go, primitive reflexes (grasp, palmomental, pout).
Cerebellar (DANISH): Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred staccato speech, Heel-shin and hypotonia. Add Romberg's and gait.
Cardiovascular: hands, face, JVP, carotids, praecordium, four areas plus manoeuvres, lung bases, ankles. Offer BP, ECG, peripheral pulses, fundoscopy.
Thyroid: inspect, swallow test, palpate from behind, repeat swallow, nodes, bruit. Then reflexes, proximal myopathy, pretibial myxoedema.
Respiratory: inspection and hands, trachea, expansion, percussion, auscultation, vocal resonance, sacral and leg oedema. Antipsychotics roughly double pneumonia risk.
Abdominal: light then deep palpation across nine regions watching their face, organomegaly, shifting dullness, bowel sounds. Clozapine constipation can be fatal: always ask about bowel habit.
Fundoscopy: red reflex, follow in nasally, disc, vessels, macula. Offer acuity, colour vision and pupillary reflexes.
Offer to complete the examination, and then report your findings and what they mean.
Give encouragement if the patient struggles, and thank them. Comfort improves the accuracy of tone and tremor.

Ask It Like This

"Is there any pain anywhere before I start?"
"I'll explain what I'm doing as I go, stop me any time."
"Say 'British constitution' for me."
"To finish, I'd like to check your blood pressure and arrange an ECG."

Risk

Report the safety-critical finding explicitly: constipation on clozapine, QTc, falls, aspiration, Wernicke's.
If the examination reveals a medical emergency, say what you would do about it today.
Do not forget the psychiatric risk in a physical station: the alcohol patient with a plan to overdose still needs it summarised.

Example Stations Covering This Theme

Frontal Lobe, Neurological, Cardiovascular, Thyroid, Fundoscopy, Respiratory, Abdominal, Cerebellar.

ECG interpretation

60-Second Summary

One system, spoken aloud, every time, even when the ECG is normal.

In the Room

Even a normal ECG deserves the full systematic run-through. That is what is being marked.

Spot It

QTc above 500ms is the action threshold. Say 'urgent' and do something about it today.
There are usually two contributing causes, not one: the drug and the electrolyte. Name both.
Diabetics and women present atypically with MI. 'Indigestion' is a presenting complaint.

Must Cover

The system: rate → rhythm → axis → P wave → QRS → ST → T → QTc. Point at the trace as you go.
Rate: QRS complexes in ten seconds × 6. Rhythm: sinus, AF, or block: first degree, Mobitz I, Mobitz II, complete.
QRS broad means bundle branch block or ventricular origin. LBBB obscures MI diagnosis.
ST elevation: convex with reciprocal depression in a territory = STEMI; widespread concave with PR depression = pericarditis; diffuse variable change on clozapine = myocarditis.
Clozapine myocarditis carries mortality up to 50% untreated: stop the drug and refer to cardiology urgently.
T waves: inversion means ischaemia until proven otherwise; tall tented means hyperkalaemia and is an emergency.
QTc upper limits 440ms in men, 460ms in women. Causes: low potassium, calcium or magnesium; antipsychotics (lurasidone lowest risk); high-dose citalopram; TCAs; methadone; macrolides; antimalarials.
Why a pre-clozapine ECG: to exclude pre-existing arrhythmia, QTc prolongation and ischaemia before starting.
Explain the finding in plain language: 'the heart is taking too long to recharge between beats'.

Ask It Like This

"Have you started any new medicines recently, including antibiotics?"
"Have you had any chest discomfort, or anything you put down to indigestion?"
"Has anyone in the family died suddenly and young?"
"Can I explain what we've found on the tracing?"

Risk

QTc over 500ms: torsades. Stop the offending drug, correct electrolytes, cardiology input.
STEMI: emergency transfer for reperfusion. Aspirin, analgesia, primary PCI.
Long-term: antipsychotic-driven dyslipidaemia and metabolic risk. Diet, exercise, statins.

Example Stations Covering This Theme

ECG interpretation, QTc Prolongation, Myocardial Infarction, Presenting an ECG.

Older Adults

Dementia: collateral history and telling the subtypes apart

60-Second Summary

The shape of the decline gives you the subtype. Steady, stepwise, fluctuating, or personality-first: ask which.

In the Room

The relative is frightened and often has just been assaulted or has just found him in the road. Acknowledge that before the checklist.

Spot It

Steady non-fluctuating decline with no hallucinations and no personality change points to Alzheimer's. Say why you have excluded the others.
Frontotemporal is disproportionately common between 45 and 65. Young onset means ask the family history.
Abrupt onset over days with drowsiness and day–night reversal is delirium, not dementia. Find the physical cause.
In the wandering station the wife died two months ago. Recent loss changes the whole formulation.

Must Cover

The five A's: Amnesia, Aphasia (expressive, receptive, anomia), Apraxia, Attention, Agnosia, plus Awareness and orientation.
Vascular: stroke or TIA, vascular risk factors, stepwise or sudden onset.
Lewy body: visual hallucinations, marked fluctuation, falls, parkinsonism, REM sleep behaviour disorder, antipsychotic sensitivity.
Frontotemporal: disinhibition, apathy, hyperorality, repetitive behaviour, executive failure, language change, with memory relatively spared early.
Always screen the reversible causes: depression as pseudodementia, alcohol, anticholinergic and sedating medication, B12, thyroid, sensory impairment.
Delirium: acute onset, fluctuating course, inattention, altered consciousness, hallucinations, sleep–wake reversal. Then hunt the cause: infection, constipation, retention, medication, electrolytes, pain.
Premorbid function and occupation, to establish the baseline you are measuring against.
Timeline everything against life events, medication changes and physical illness.

Ask It Like This

"Has it come on gradually, or in steps, as though something happened, then it settled?"
"Does he have good days and bad days, or is it much the same all the time?"
"Has he seen anything that wasn't there, people or animals?"
"Is he still the same person, in terms of character and temperament?"

Risk

Wandering, and what happened this time: door left open, clothing, time of day, destination.
Fire and gas: the hob, smoking, working smoke alarm.
Driving, finances and exploitation. Ask about all three by name.
Self-neglect, medication errors and falls. And in frontotemporal dementia, aggression: this station opens with a strangulation.

Example Stations Covering This Theme

Alzheimer's Collateral, Frontotemporal Dementia, Wandering, Delirium Collateral.

Explaining a dementia diagnosis

60-Second Summary

Four learnable scripts. What separates them is what you say about treatment, and in Lewy body, what you say about antipsychotics.

In the Room

If they look overwhelmed, stop and re-explain more simply. Ploughing on is the commonest failure here.

Spot It

Never give an antipsychotic in Lewy body dementia. Neuroleptic sensitivity can be fatal. Say it unprompted.
Cholinesterase inhibitors do not help pure vascular dementia, and are not indicated in MCI at all.
MCI is decline without functional impairment. That distinction is the entire station.
Timeline separates Lewy body from Parkinson's dementia: cognition first, or motor first by a year or more.

Must Cover

Dementia is an umbrella term: progressive, irreversible, global decline in clear consciousness.
Alzheimer's: amyloid plaques and tau tangles; age is the biggest risk factor; cholinesterase inhibitors do not cure but may slow it, starting low because of GI side effects.
Vascular: damaged or blocked cerebral vessels, stepwise course. Treatment is optimising vascular risk factors and lifestyle. Not inherited, though the risk factors run in families.
Lewy body: alpha-synuclein deposits; memory plus movement problems, vivid visual hallucinations, marked fluctuation, falls, REM sleep disturbance. Cholinesterase inhibitor first line, memantine second.
MCI: cognitive decline beyond that expected for age but function preserved. No drug treatment. Optimise physical health and review in six to twelve months.
Psychosocial in all four: reminiscence, music, routine, activity, carer support groups, OT home assessment, dosette box, befriending.
Prognosis honestly: variable, progressive, and no cure. Do not promise a plateau.
Offer written information, a carer's assessment, and a follow-up appointment.
Consider signposting lasting power of attorney, health and welfare and property and finance, while capacity remains.

Ask It Like This

"What's your understanding of what the scan and the tests showed?"
"What worries you most about the future?"
"That was a lot, can I check what you've made of it so far?"
"Have you had any thoughts about how you'll manage day to day?"

Risk

Driving: raise it yourself in the vascular and Lewy body stations.
Falls in Lewy body; wandering in Alzheimer's; stroke risk in vascular.
Carer strain and the carer's own mental health.
Financial capacity and exploitation.

Example Stations Covering This Theme

Alzheimer's Explanation, Vascular Explanation, Lewy Body Explanation, Mild Cognitive Impairment.

Behavioural disturbance and late-life psychosis

60-Second Summary

Before you reach for an antipsychotic, look for pain, infection, constipation, a new drug and a changed carer.

In the Room

Let an angry relative or an angry patient finish. Validate the emotion, for example 'it sounds like you're angry that nobody told you', before you explain anything.

Spot It

In BPSD the answer is never 'increase the risperidone'. Exclude a physical cause and exhaust non-drug options first.
Delusional disorder: a single circumscribed, plausible-sounding belief with preserved function and no negative symptoms.
An olfactory hallucination should make you ask about seizures as well as psychosis.
Hoarding is its own diagnosis, not simply OCD, but screen OCD, ASD, psychosis and bereavement underneath it.

Must Cover

BPSD affects around 90% of people with dementia and signals progression.
Rule out first: infection, pain, constipation, urinary retention, medication side effects, glucose, a change in carers or visitors. Trial paracetamol for undisclosed pain.
Non-drug first line: ABC charting to find triggers, individualised music, reminiscence, pet therapy, natural light, routine.
Risperidone is the only UK-licensed antipsychotic for BPSD. Lowest dose, shortest duration, around six weeks, regular review. Never in Lewy body or Parkinson's.
Be upfront about antipsychotic risks: sedation, falls, EPSE, QTc, stroke, oedema, metabolic effects. Baseline and follow-up monitoring.
Avoid benzodiazepines. Antidepressants only if there is genuine depression.
Delusional disorder: test conviction, screen all modalities, note preserved thought form, and assess insight honestly.
Cotard's and nihilistic delusions: link the belief to the reduced oral intake. That link is the risk.
Hoarding: establish meaning and reaction to removal; fire risk, blocked exits, trip hazards, smoke alarm, offer a fire safety check.

Ask It Like This

"Has anything changed for him in the last few weeks, his medication, his health, who visits?"
"When it happens, what tends to come just before it?"
"What do you think would happen if the papers were cleared away?"
"Some people feel that things have gone wrong inside their body. Has anything like that crossed your mind?"

Risk

In psychotic depression, oral intake and dehydration are the acute risk. Ask what they have eaten today.
In delusional disorder, ask whether they intend to act on the belief: confront the neighbour, retaliate.
In hoarding, fire is the specific risk that must be named.
In BPSD, risk to staff and other residents, and risk to the patient from restraint.

Example Stations Covering This Theme

BPSD, Delusional Disorder, Hoarding, Psychotic Depression (Cotard's).

Capacity, cognition and lobar examination in the older adult

60-Second Summary

Know the domains, not one named test. And when capacity is present, say so and support the decision anyway.

In the Room

If you are combining a cognitive screen with a lobar examination, do not test the same thing twice.

Spot It

The instructions here support capacity: intact cognition and clear reasoning. Do not manufacture incapacity because the decision is unwise.
Examiners want the cognitive domains. Do not panic about exact ACE-III wording.
Check hearing and vision before you start. Sensory impairment fakes cognitive impairment.

Must Cover

Capacity: understand, retain, weigh, communicate. Assess at the best time and in the best circumstances. An unwise decision is not incapacity.
Having concluded capacity is present, still make the discharge safe: GP follow-up, OT and physio, pendant alarm, befriending, an emergency plan.
Cognitive domains: attention (orientation, serial sevens, registration), memory (three words, recent and remote, semantic), fluency (letter and category, one minute), language (repetition, writing), visuospatial (clock face).
Parietal, dominant (Gerstmann's): finger agnosia, right–left disorientation, dyscalculia, dysgraphia.
Parietal, non-dominant: dressing apraxia, neglect, anosognosia, constructional apraxia, topographical disorientation.
Parietal, bilateral: astereognosis, agraphaesthesia, prosopagnosia, lower quadrantanopia.
Temporal: memory across all timescales, repetition, alexia, agraphia, object naming, prosopagnosia, upper quadrantanopia, plus screening for epileptic phenomena and psychosis.
Screen pseudodementia (mood, anxiety, recent medication change) before concluding dementia.
Explain and consent before you start, and offer a chaperone. Encourage if they struggle.

Ask It Like This

"Can you tell me what you think would happen if you went home without carers?"
"I'm going to give you a name and address to remember, I'll ask you again at the end."
"Show me your right index finger, then touch your left ear with your right hand."
"Some of these are meant to be hard, just do your best."

Risk

Falls, malnutrition, self-neglect and isolation, and note the protective factors, such as neighbours.
Look for a reversible physical cause of falls: mobility, vision, postural hypotension.
State your conclusion on capacity plainly, and tell the patient what it is.

Example Stations Covering This Theme

Capacity Assessment, Cognitive Examination, Parietal Lobe, Temporal Lobe.

Child and Adolescent Psychiatry

Neurodevelopmental collateral history

60-Second Summary

You are interviewing a parent about a child you will never meet. Ask about everyday activities, not abstract capacities.

In the Room

You do not have to state the diagnosis unless asked, but your questions must show which one you are hunting.

Spot It

Ask in examples, such as 'how long can he sit with a book?', not 'can he concentrate?'. This is explicitly what good candidates do.
Symptoms must be present in more than one setting and beyond normal variation for age. Ask about school and home separately.
Focused attention on video games does not exclude ADHD.
In ASD, ask about pretend play and interest in parts of objects rather than whole objects.

Must Cover

ADHD: inattention (distractible, disorganised, forgetful, loses things), hyperactivity (fidgety, noisy, out of seat), impulsivity (interrupts, cannot wait). Six months, developmental onset, functional impairment, more than one setting.
ADHD risk factors: family history, prematurity, low birth weight, maternal smoking or substance use in pregnancy, head injury.
ASD: impaired social communication and reciprocal interaction, and restricted, repetitive, inflexible behaviours and interests, with sensory sensitivity, developmental onset, functionally disabling.
Screen the alternatives explicitly: specific learning difficulty, oppositional defiant or conduct disorder, developmental language disorder, attachment disorder, intellectual disability, psychosis, Rett syndrome.
ADHD and ASD are frequently comorbid with each other, and with anxiety, depression and tics. Screen both ways.
Birth and pregnancy history, developmental milestones, physical health.
Establish functional impact concretely: school reports, friendships, family life, exclusions.
Open questions early, closed questions later. There is a lot of ground and only seven minutes.

Ask It Like This

"How long can he stay with something he doesn't especially enjoy?"
"What does he do when he plays on his own?"
"Is he the same at school as he is at home?"
"How did he get on with talking and walking as a toddler?"

Risk

Impulsivity causing accidental injury, and deliberate self-harm including head-banging.
Aggression to others, and vulnerability to bullying, exploitation or punitive parenting.
Ask about screen use, sleep and, in adolescents, substances.
Safeguarding: ask how the parents manage the behaviour.

Example Stations Covering This Theme

ADHD Collateral, ASD Collateral, Adult ADHD.

Explaining a neurodevelopmental diagnosis to a parent

60-Second Summary

A sceptical parent who thinks it is bad behaviour, or a confused one asking why it was missed until now.

In the Room

Be comfortable saying there is no cure, while still describing real and useful support. That combination is what is being marked.

Spot It

Say plainly that this is not bad parenting and not an excuse. That misconception is the station.
Late diagnosis in girls is expected: masking and compensation mean symptoms surface under social demand in adolescence.
Asperger's is an old term now folded into the autism spectrum. Explain it without dismissing their use of it.
There is no cure and no medication for ASD itself. Say so comfortably.

Must Cover

ADHD: neurodevelopmental, strongly heritable, plus environmental factors. More often recognised in boys.
ADHD stepped management: psychoeducation and support → environmental and school modification → stimulant medication → CBT for residual difficulties.
Stimulant side effects: appetite suppression and growth, GI upset, dizziness; cardiac caution; monitor height, weight, BP and pulse, and get an ECG if there is a cardiac history.
ADHD prognosis: hyperactivity tends to recede, inattention tends to persist; around 15% keep the full diagnosis into adulthood.
ASD management: no cure; NICE-guided MDT approach: information and signposting, social communication interventions, sleep and behaviour support, carer's assessment. Low-dose risperidone or aripiprazole off-label only for challenging behaviour, and late in the sequence.
ASD comorbidity: sleep problems, ADHD, anxiety, conduct disorder.
In learning disability, pitch language to the person, use diagrams, and ask them to say it back, without being patronising.
Offer easy-read leaflets, national charities, and a follow-up appointment.
Chunk and check throughout. These are information-dense stations.

Ask It Like This

"What have you already been told, and what's your own view of what's going on?"
"You mentioned you think it's just bad behaviour, can I take that one directly?"
"Can you tell me back what we've agreed, so I know I've explained it well?"
"What's the one thing you most wanted to get out of today?"

Risk

Ask what has already gone wrong: exclusions, accidents, self-harm.
For stimulants, cardiac history and family history of sudden death.
For challenging behaviour, risk to the young person, to siblings and to carers.

Example Stations Covering This Theme

ADHD Explanation, ASD Explanation, Explanation in Learning Disability.

Adolescent self-harm and early-onset psychosis

60-Second Summary

Adolescents get the same structures as adults plus three things: safeguarding, collateral, and where they sleep tonight.

In the Room

They have often already told the story to three people in ED. Acknowledge that, and they will tell it to you properly.

Spot It

The default after adolescent self-harm is overnight admission to a paediatric ward with full assessment the next day, not discharge from ED at night.
The precipitant is usually social: bullying, a group chat, an exclusion. Follow the cue rather than the checklist.
The pressure often comes from a bed-stretched colleague. Hold the line without losing the working relationship.
Involve parents and school, and consider whether safeguarding needs triggering.

Must Cover

Risk structure as for adults: before, during, after, now, with planning, final acts, precautions against discovery and perceived lethality as the red flags.
Protective factors and the young person's own view of what would help. Very heavily marked in CAMHS.
Screen the underlying disorder: depressive syndrome over the preceding months, ADHD-driven impulsivity, psychosis, substance use.
Why overnight admission: safety, time to gather collateral from family, school and social care, and senior CAMHS review in working hours.
If discharged, community CAMHS follow-up within seven days.
Early-onset psychosis: full MSE plus first-rank symptoms, and screen organic causes: head injury, epilepsy, substances.
Differentials to state: early-onset schizophrenia, schizoaffective, acute and transient psychotic disorder, organic, substance-induced.
Psychosis management for a parent: exclude organic causes, likely inpatient admission with senior CAMHS input, possible detention framed as protective with a right of appeal, antipsychotic plus family intervention and CBT.
Adolescent mania: run the MSE inside a light history, and always ask directly about delusions and hallucinations.

Ask It Like This

"What was happening in the days before?"
"Who knows about this, and who would you want to know?"
"If things got that bad again, what would you want to happen?"
"Is there anyone at school or at home you'd feel able to talk to?"

Risk

Ongoing intent, and whether the home is safe tonight: supervision, access to means, who is there.
Safeguarding: bullying, abuse, neglect, online exploitation.
In mania, vulnerability through disinhibition and raised libido, and risk from others.
Always ask what happened after: how they were found, and whether they told anyone.

Example Stations Covering This Theme

Adolescent Overdose Risk, Overdose Management, Early-Onset Psychosis History, Early-Onset Psychosis Management, Adolescent Mania.

Learning Disability Psychiatry

Learning disability: change in behaviour and diagnostic overshadowing

60-Second Summary

New behaviour in a person with learning disability is a physical illness until proven otherwise.

In the Room

Do not accept 'that's just how he is' from anyone, including yourself.

Spot It

Diagnostic overshadowing is the trap that defines this chapter: attributing everything to the learning disability and stopping the workup.
There is usually more than one answer: a mood disorder and an untreated physical problem together. Find both.
Down's syndrome carries a high dementia risk from a young age, and cataracts and earwax fake cognitive decline.
A breakthrough seizure after ten years is a finding, not background.

Must Cover

Biological: undiagnosed physical illness, pain, constipation, infection, dental problems, epilepsy, sensory impairment, medication change.
Psychological: comorbid mental illness is common, including depression, anxiety, psychosis, mania, ADHD, ASD, dementia. Unprocessed trauma.
Social: changed relationships, reduced visits, new staff, moves, bereavement, and signs of abuse.
Take a collateral history from someone who knows them well, and establish the premorbid baseline.
Screen depression through observable change: withdrawal, tearfulness, sleep, appetite, weight, loss of interest in what they used to enjoy.
For cognitive decline, ask about getting lost, face recognition, self-care and ADLs, not just memory.
It is entirely acceptable, often correct, to conclude the picture is multifactorial. Say so rather than forcing one label.
Consider the ageing carer and what happens when they can no longer cope.

Ask It Like This

"What was he like six months ago, compared with now?"
"Has anything changed for him, staff, visitors, where he lives?"
"When did he last open his bowels?"
"Does the behaviour happen with everyone, or only in certain situations or with certain people?"

Risk

Always ask about abuse: physical, sexual, financial. Behaviour confined to one person or one situation, new bruising or new incontinence are the flags.
Self-injury including head-banging, which is commoner in this population.
Aggression, and what has been tried; setting safety for staff and other residents.
Wandering, road safety, medication adherence, home hazards, exploitation.

Example Stations Covering This Theme

Recent Change in Behaviour, Down's Syndrome.

Capacity in learning disability

60-Second Summary

Three capacity stations, three different answers. The structure is identical; the conclusion is not.

In the Room

Never argue them into agreeing. Testing understanding is not the same as persuading.

Spot It

Capacity is presumed from 16 regardless of how unwise the decision looks. Rebut it with evidence or accept it.
The limb that fails is usually weighing: a fixed belief that contradicts the facts. That is the failure, not the belief itself.
Maximise capacity before you assess it: best time, best circumstances, simplest language, visual aids.
Address the practical worry underneath, who is looking after anyone they are currently caring for, even though it does not restore capacity.

Must Cover

An impairment of mind or brain must be present, and then inability on at least one of the four limbs.
Understand: explain, then ask them to tell it back. Retain: long enough to decide. Weigh: can they balance it. Communicate.
Explain the actual consequences of refusal in concrete terms, without minimising them.
If incapacitous, the decision is made in best interests: past and present wishes, any advance decision, and the views of those who know them.
Nobody, capacitous or not, can demand treatment that is not clinically appropriate.
For irreversible or life-threatening decisions, say that this would in practice go to court.
State your conclusion, and tell the person what it is and what happens next.
Simple, concrete language; check jargon as you go; offer visual aids.

Ask It Like This

"Tell me if anything I say is confusing and I'll say it a different way."
"Can you tell me in your own words what the doctors have said will happen without the operation?"
"What made you decide against it?"
"Is there anything worrying you about being here that I could help with?"

Risk

Name the consequence of the refused treatment specifically: death, irreversible harm, complications.
Check for a treatable cause of the incapacity: delirium, pain, infection, depression, psychosis.
Consider who else is affected: dependants, and anyone they are currently caring for.

Example Stations Covering This Theme

Capacity to Refuse Surgery, Capacity to Refuse Insulin, Capacity to Refuse Carers.

Forensic Psychiatry

Sexual offending and paraphilia

60-Second Summary

Take a full psychosexual history without flinching, and map the escalation from fantasy to behaviour.

In the Room

Shame prevents disclosure. Validate the act of coming forward and you will get more of the history.

Spot It

Escalation is the risk. Fantasy → images → arousal in a real situation with access → planning. Track where on that line they are.
Confidentiality is not absolute. Explain the limits calmly if asked: serious harm and serious crime.
Occupational or domestic access to children is the safeguarding fact.
Test whether they believe the other person reciprocates. If they do, this is erotomania, not exhibitionism.

Must Cover

Psychosexual history in full: orientation, relationships, pornography use, fantasies and fetishes with type and frequency, sexual difficulties, previous inappropriate behaviour, previous offences.
Chronology of the behaviour: when it started, how often, whether it has changed.
Ask specifically about access to children, and about any contact offence.
Screen major mental illness as an explanation: psychosis, mania, ASD, and in older patients frontotemporal disinhibition.
Insight: do they see the behaviour as wrong, and do they believe it is reciprocated.
Protective factors: self-presentation for help, willingness to disclose, engagement, absence of contact offending.
Substance use and forensic history.
Paedophilia is the disorder; child sexual offending is the crime. They are not synonymous, but safeguarding duties apply regardless.

Ask It Like This

"I know some of this is embarrassing to talk about, but I need to ask directly."
"Has it ever gone further than thinking about it?"
"Do you spend time around children, through work or otherwise?"
"What made you decide to come and talk to someone today?"

Risk

To identifiable children or adults: who, and what access do they have.
To the public, through the pattern and previous offences.
Self-harm and suicide, which are markedly raised in this group.
Legal risk: possession of indecent images is itself an offence, and disclosure triggers duties.

Example Stations Covering This Theme

Indecent Exposure, Paedophilia.

Delusional jealousy and erotomania

60-Second Summary

Both are delusional disorders, both carry serious violence risk, and both are missed because function is otherwise preserved.

In the Room

A partner who finds the jealousy flattering is still in danger. Do not let their minimising soften your account of the risk.

Spot It

Follow the ominous phrase. 'One way or another' is an invitation to ask what they mean, and it is where the risk is.
A real past affair does not exclude morbid jealousy. The diagnosis rests on the delusional interpretation of the evidence.
Concrete preparation, such as buying a knife, researching methods, booking flights, moves this from belief to plan.
If asked to name it, say the subtype: erotomanic type, or Othello syndrome. Vague 'delusional disorder' is not enough.

Must Cover

Delusional disorder: a fixed delusion for three months or more, no schizophrenia-type symptoms, not a mood episode, not substance-induced, with function otherwise preserved.
Test conviction to separate delusion from overvalued idea, then map the behaviour it has driven: checking, surveillance, following, confronting, contacting, preparing.
Erotomania: belief that another, often unattainable or of higher status, is in love with them, supported only by innocuous 'evidence'.
Morbid jealousy: delusional conviction of infidelity, built on trivial evidence, often circumscribed and therefore undetected until police involvement.
Screen alternative diagnoses: schizophrenia, schizoaffective, bipolar, drug-induced and organic psychosis, including frontal lesions.
Management: antipsychotic is the mainstay; limited evidence for CBT; formal violence and stalking risk assessment.
Immediate management: medical clearance, capacity for informal admission versus detention, and the right setting: ward, PICU or forensic. Ask for forensic advice if unsure.
Social: possible restraining order, community follow-up, Fixed Threat Assessment Centre for public-figure risk, support with housing, work and finances.
When explaining to a partner, check what they already know before disclosing psychiatric or forensic history.

Ask It Like This

"You said you'd sort it out one way or another. What did you mean by that?"
"What would you do if you saw them together?"
"Have you done anything to prepare, bought anything, planned anything?"
"Is there any possibility, even a small one, that you've got this wrong?"

Risk

Serious violence and homicide toward the partner or supposed rival. A previous violent conviction plus concrete planning is the highest-risk combination in this chapter.
Stalking, harassment and breach of any existing order.
Suicide, particularly if the belief collapses or the relationship ends.
Risk to the person's own employment, finances and liberty.

Example Stations Covering This Theme

Morbid Jealousy Risk, Erotomania Risk, Erotomania Management, Morbid Jealousy Explanation.

Fire-setting and violence risk

60-Second Summary

Establish the meaning of the act, then structure everything else around past, present and future.

In the Room

Stay calm and unshockable. A candidate who visibly recoils gets less history and fewer marks.

Spot It

Ask what the fire or the assault meant to them. Revenge, relief, arousal, control, self-harm or psychosis: the meaning drives the risk.
A recent assault, absent remorse, and a stated willingness to repeat it. Those three facts are the assessment.
Insight into danger and consequences is protective. Its absence is not neutral.
No named tool is expected in seven minutes. A clear structure is.

Must Cover

Past: previous violence and fire-setting, forensic history and disposals, prison, PICU or forensic admissions, mental illness, personality disorder, substances, engagement with treatment, employment and relationships.
Present: full MSE, the intent behind the index act, provoked or premeditated, weapons, the specific target, substance involvement, current insight.
Future: remorse, stated intent to repeat, ongoing precipitants, and protective factors.
Pyromania: recurrent uncontrolled fire-setting with no other apparent motive, fascination with fire, tension before, relief and gratification after, excluding cognitive impairment, other mental disorder and intoxication.
Screen the comorbidities that change the formulation: psychosis, depression, learning disability, personality disorder, substance use.
Screen risk to self alongside risk to others. Candidates routinely omit it in violence stations.
Ask what has been tried before and what helped.
Identify further collateral: police records, family, GP, previous notes.

Ask It Like This

"What was going through your mind just before it happened?"
"How did you feel afterwards?"
"Do you think it could happen again?"
"Was there anything that would have stopped you?"

Risk

Identified targets, and whether they are accessible right now.
Access to weapons, accelerants or means.
Ward safety, staff safety and other patients: say what you would do today.
Self-harm, and vulnerability to retaliation from others.

Example Stations Covering This Theme

Pyromania, Violence Risk Assessment.

Addiction Psychiatry

Alcohol withdrawal and its emergencies

60-Second Summary

Seventy-two hours since the last drink, confused and seeing insects. Ask when they last drank: that one question is the station.

In the Room

Distract and reassure rather than argue about the insects. Agitation falls when the patient feels safe.

Spot It

Delirium tremens is a medical emergency with real mortality. Say the word 'emergency'.
Timing matters: withdrawal at 6–12 hours, seizures around 24–48, delirium tremens at 72–96.
Pabrinex before glucose, always: glucose first can precipitate Wernicke's.
Avoid antipsychotics in withdrawal: they lower the seizure threshold, and the hallucinations respond to benzodiazepines.

Must Cover

Delirium tremens: confusion, fluctuating consciousness, vivid visual and tactile hallucinations, agitation, tremor, and autonomic hyperactivity: tachycardia, hypertension, sweating, fever.
Differentiate from delirium of other cause, from primary psychosis, and from alcoholic hallucinosis (hallucinations without confusion or physical signs).
Immediate management: treat co-existing illness, IV fluids, correct electrolytes, monitor with CIWA-Ar, symptom-triggered chlordiazepoxide, IV thiamine.
Nursing and environment: side room, good light, visible clock, reorientation, one-to-one observation, interpreter if needed.
Longer term: acamprosate or disulfiram after detox, oral thiamine, motivational work, community alcohol service, and signposting to AA or equivalent.
Cerebellar signs (DANISH), plus Romberg's and gait. Wernicke–Korsakoff patients confabulate; be patient and repeat instructions.
Wernicke's triad: confusion, ataxia, ophthalmoplegia. Treat on suspicion.
Explain to a colleague at the right register: informative without being patronising.

Ask It Like This

"When did you last have a drink?"
"What are you seeing? Can you describe it to me?"
"How much would you normally drink in a day, and since when?"
"Have you ever had a fit, or the shakes, when you've cut down before?"

Risk

Death from untreated delirium tremens, seizures, arrhythmia and dehydration.
Falls, and Wernicke's progressing to Korsakoff's.
Aspiration and injury during agitation.
Suicide risk once alert: do not omit it from the summary.

Example Stations Covering This Theme

Delirium Tremens MSE, Delirium Tremens Management, Cerebellar Examination.

Substance dependence: alcohol, opioids and novel drugs

60-Second Summary

Get the substance history in numbers, then decide whether the psychiatric symptom is cause, consequence or coincidence.

In the Room

Normalise the questioning openly, for example 'I ask everyone this', and irritable, defensive patients settle.

Spot It

Ask 'when did you last drink?' rather than 'do you drink?'. It gets a straighter answer.
Establish chronology: did the drinking follow the symptom or precede it? Escalating use after a psychotic or mood symptom is consequence, not cause.
Never give methadone without confirming the actual dose and last dispensed date. Iatrogenic overdose is the risk you own.
Evasion about drug use or sexual history is a cue to build rapport, not to stop asking.

Must Cover

For every substance: type, amount, frequency, route, pattern through the day, duration, last use, spend, and how it is funded.
ICD-11 dependence: three or more of compulsion, impaired control, withdrawal, tolerance, neglect of other interests, continued use despite harm, narrowing of repertoire.
Alcohol-related physical harm: memory, liver, neuropathy, ataxia, seizures, pancreatitis.
Alcohol-induced psychotic disorder: psychotic symptoms during or shortly after intoxication or withdrawal, not better explained by a primary psychotic disorder. Usually self-limiting with abstinence.
Opioids: methadone withdrawal starts at 24–48 hours, heroin at 4–6. Uncomplicated withdrawal is not life-threatening; overdose is. Symptomatic options if methadone cannot be confirmed. Offer take-home naloxone.
Injecting practice: needle-sharing, blood-borne virus testing, track marks. Ask, and consider examining.
GHB/GBL: narrow therapeutic index, rapid CNS and respiratory depression, dangerous with alcohol. Chemsex context: consent, condom use, PrEP, sexual health screening.
Methadone in pregnancy: continue it. Detox risks miscarriage in the first trimester and stillbirth in the third. Neonatal abstinence syndrome is expected and manageable; breastfeeding is encouraged and reduces it.
Establish whether an overdose was accidental or intentional: screen mood, past psychiatric history and intent.

Ask It Like This

"When did you last use?"
"Walk me through a typical day, when's the first one?"
"What happens if you go without?"
"Have you ever taken more than you meant to, or had a scare?"

Risk

Overdose, intentional and accidental, and previous overdoses.
Relapse risk if withdrawal is untreated, and the exploitation and offending that follow.
Blood-borne viruses, injecting complications, and sexual risk including non-consensual activity.
Driving, fire risk, and risk to dependants and children.

Example Stations Covering This Theme

Alcohol Dependence, Alcohol-Induced Psychosis, Opiate Dependence, GBL and Chemsex, Methadone in Pregnancy.

Psychotherapy

Explaining the behavioural and cognitive therapies

60-Second Summary

Explain the mechanism, not the timetable. Draw the anxiety curve and tie it to their actual symptom.

In the Room

Do not lecture. 'What would you be willing to try this week?' turns the station into a collaboration.

Spot It

Draw or describe the anxiety curve: it rises, peaks, and falls within the hour if you neither avoid nor escape. That is the whole explanation.
Testing conviction is the task. A distortion softens under evidence; a delusion does not.
If ERP is not working despite compliance, suspect a hidden or purely mental compulsion.
Be flexible about format: home visits and telephone sessions are reasonable early on.

Must Cover

Name the distortions you actually hear: minimisation, maximisation, selective abstraction, arbitrary inference, catastrophising, black-and-white thinking, personalisation, overgeneralisation.
Name it gently and check it resonates, rather than announcing it.
Graded exposure: build a hierarchy from tolerable to difficult, stay with each step until anxiety falls, then move up. Extinction, then habituation.
Systematic desensitisation adds a relaxation technique paired with exposure: you cannot be relaxed and anxious at once.
OCD cycle: trigger → obsessional thought → meaning → compulsion → temporary relief → stronger trigger. ERP breaks the link by preventing the response.
CBT for OCD adds structured homework and behavioural experiments; combined with an SSRI it is NICE-recommended.
Build safety into the plan: pitch each step as tolerable, and agree what they do if it becomes overwhelming.
Check retention as you go: anxious patients hold very little.
Say what happens if this step fails: MDT discussion, medication change, specialist services.

Ask It Like This

"If you stayed with it and didn't leave, what do you think would happen to the anxiety?"
"What's the smallest step you'd be willing to try this week?"
"That sounds like what we'd call catastrophising, does that fit for you?"
"Is there anything you do in your head to make the feeling go away?"

Risk

Ask about suicidal ideation explicitly, even in a therapy station. It is marked.
Family history of suicide, and previous attempts.
Alcohol or substance use as a coping strategy, which raises impulsive risk.
Agree a crisis route before you start exposure work.

Example Stations Covering This Theme

Cognitive Distortions, Systematic Desensitisation, Exposure and Response Prevention.

Explaining the relational therapies

60-Second Summary

Know structure, mechanism and indication for each modality: how long, how often, what happens, and when it is used.

In the Room

You are usually meeting them once. Contain, normalise, and hand back to the treating therapist.

Spot It

Never imply one therapy is better than another. NICE supports a range; the fit differs.
Your job here is to normalise the transference and send it back to her therapist, not to interpret it yourself.
Parents offered family therapy usually fear they are being blamed. Defuse that before you describe anything.
Validate the frustration that the first therapy did not work, rather than defending the earlier choice.

Must Cover

IPT: 12–16 weeks with homework, beginning with assessment sessions. Four domains: role transitions, grief and loss, interpersonal disputes, and difficulty forming or keeping relationships.
IPT differs from CBT by working on relationships and life events rather than cognitions.
Transference: feelings from an early relationship unconsciously re-enacted onto a current one, including the therapist. Draw the parallel across past, present and the therapeutic relationship.
The urge to leave first, rather than risk being left, is the thing to name and resist.
Family therapy has two main approaches. Structural: repairing disrupted hierarchy and roles, therapist may temporarily take sides. Systemic: the family as a system, circular questioning, sometimes a reflecting team behind a screen.
Typical family therapy shape: roughly fortnightly over three to six months, and not every session needs everyone.
Combination of therapy and medication generally beats either alone. Say so.
Good prognostic signs: motivation, psychological-mindedness, prior engagement.
Relative contraindications: florid psychosis, significant untreated substance misuse, inability to stay safe between sessions.

Ask It Like This

"What was it about the last therapy that didn't fit?"
"Would you be able to take these feelings back to your therapist and say them out loud?"
"Nobody here thinks this is anyone's fault, can I say why we've suggested it?"
"What would you most want to change by the end?"

Risk

Check they can manage safely between sessions, and agree what they do if they cannot.
Ending therapy abruptly is itself a risk: say why continuing is safer.
In family therapy, screen for domestic conflict and its impact on the child.

Example Stations Covering This Theme

Interpersonal Therapy, Transference, Family Therapy.

Eating Disorder Psychiatry

Eating disorders: assessment, explanation and physical safety

60-Second Summary

The psychological history earns the pass; the physical risk stops you failing.

In the Room

Acknowledge disclosures without criticising or coddling. Shame drives the illness, and it is being observed.

Spot It

MARSIPAN bands: BMI over 15 low risk, 13–15 medium, under 13 high. Quote them.
Re-feeding kills through electrolyte collapse, not starvation. Explain the mechanism, do not just say 'go slowly'.
Russell's sign, parotid swelling and heartburn are the physical tells of purging. Recognise them by name.
Never promise weight loss in bulimia. Regular eating comes first; weight is a separate, later goal.

Must Cover

Anorexia: BMI under 18.5, self-induced weight loss, weight gain prevented by restriction, purging or exercise, and preoccupation with or misperception of weight and shape.
ICD-11 nuance: fear of fatness is no longer required; it is typically associated, or low weight is central to self-identity, or normal weight is perceived as excessive.
Eating detail: calorie counting, weighing, goal weight, highest and lowest weight, avoided foods, rituals such as cutting, mashing, separating.
Physical risk: rapid weight loss, weakness and difficulty standing unaided (SUSS test), palpitations, amenorrhoea, fractures. Bloods: potassium, magnesium, phosphate, glucose, LFTs, FBC. ECG: bradycardia, long QTc, ST and T changes.
Re-feeding mechanism: starvation depletes potassium, magnesium and phosphate and suppresses insulin; food raises glucose, insulin surges, synthesis restarts, the depleted minerals are consumed, serum levels crash, and arrhythmia follows.
Re-feeding management: slow reintroduction with dietician oversight, ECG and bloods, thiamine, vitamin B co-strong and multivitamin.
Bulimia: bingeing with compensatory purging at a normal BMI. Ask about laxatives, diuretics, enemas and exercise as well as vomiting.
Bulimia treatment: regular eating pattern, guided self-help, CBT or IPT, high-dose fluoxetine 60mg, dietician input. Explain that purging does not prevent absorption.
Anorexia treatment: dietician-led meal plan and eating-disorder-focused CBT; medication only for comorbidity; community unless physical risk demands admission; around 50% make a full recovery.

Ask It Like This

"What does a normal day's eating look like for you?"
"Are there foods you won't eat now that you used to?"
"Can you stand up from squatting without using your hands?"
"Do you ever do anything afterwards to get rid of it?"

Risk

Cardiac: arrhythmia from electrolyte disturbance, whether from purging or from re-feeding.
Bone: osteoporosis and fracture. Endocrine: amenorrhoea and infertility.
Self-harm and suicide, which are raised in both diagnoses.
Detention status and capacity: establish whether they can refuse treatment or leave.

Example Stations Covering This Theme

Anorexia Explanation, Anorexia History and Risk, Re-feeding Syndrome, Bulimia Nervosa.

Perinatal Psychiatry

Prescribing in pregnancy and the perinatal period

60-Second Summary

Weigh the risk of the drug against the risk of relapse, and say the second half out loud, because candidates only say the first.

In the Room

No option is risk-free. Say that, lay out the trade-offs, and let her choose.

Spot It

Continuing methadone in pregnancy is safer than stopping it. Say it plainly and early.
The historic lithium–Ebstein's link has not been confirmed by recent studies. Present the evidence as evolving, not settled.
Lithium levels fall through pregnancy and rise peripartum. Dose changes and closer monitoring follow from that.
Breastfeeding: not on lithium; encouraged on methadone. Know which way round.

Must Cover

Frame every option, including doing nothing, with its risks: switch agent, stop before conception, or continue with monitoring.
Name the risk of relapse specifically: self-harm, disengagement, harm to the pregnancy and to the infant.
Lithium monitoring in pregnancy: levels every four weeks, then weekly from 36 weeks.
Lithium teratogenicity is a caution in women; in men the conversation is about the partner's plans, not his own risk.
Methadone: not teratogenic; if detox is insisted upon, only in the second trimester under specialist supervision; dose may need increasing in the third trimester.
Neonatal abstinence syndrome: emerges after around 48 hours with poor feeding, vomiting, high-pitched cry, sneezing, poor sleep, rarely seizures. Needs neonatal unit access.
Make sure the obstetric and midwifery team know about the prescription: it changes labour analgesia and place of delivery.
Buprenorphine causes less severe NAS but has a smaller evidence base in pregnancy.
Agree a relapse plan with her and her family, and involve the perinatal team.
The decision is hers, made with full information and full support either way.

Ask It Like This

"What's worrying you most about taking it while you're pregnant?"
"Can I also tell you what the risks are of stopping?"
"Have you talked to your midwife about the prescription?"
"What would you want us to do if you started to become unwell again?"

Risk

Relapse of the underlying illness: the risk most often left unsaid.
Lithium toxicity peripartum with fluid shifts.
Illicit relapse and overdose if methadone is stopped.
Safeguarding and the need for a pre-birth plan if there is ongoing substance use.

Example Stations Covering This Theme

Lithium in Pregnancy, Methadone in Pregnancy, Lithium.

Postnatal mood and postpartum psychosis

60-Second Summary

Distinguish blues from depression from psychosis by onset and severity, then ask the question about the baby.

In the Room

She may be frightened of being detained again. Build rapport first, or the disclosures will not come.

Spot It

Postpartum psychosis is a psychiatric emergency: sudden onset within days to weeks, mood extremes with psychotic symptoms, and a high risk of harm to mother and infant.
Baby blues resolve within about two weeks and need no treatment. Depression persists beyond two weeks.
Ask what they intend to do about the delusional belief and whether they would use violence; physical incapacity is the only current barrier. Do not miss it.
Perinatal OCD hides under 'anxiety': baby-focused intrusive thoughts with compulsions.

Must Cover

Postnatal depression: core depressive syndrome persisting two weeks or more, with poor bonding and negative cognitions about herself as a mother.
Risk factors: past depression or anxiety, family history of perinatal illness, traumatic delivery, isolation, domestic abuse.
Ask sensitively about thoughts of harming the baby, and about intrusive thoughts she finds frightening. Normalise before you ask.
Postpartum psychosis: onset days to weeks after birth, especially with a history of bipolar, schizoaffective disorder or a previous episode.
Delusions in postpartum psychosis often concern the baby: swapped, not hers, or in danger. That content is the risk.
Management: urgent admission, ideally to a Mother and Baby Unit, with an antipsychotic with or without a mood stabiliser, then perinatal team follow-up.
For postnatal depression: CBT and/or antidepressant depending on severity, with an explicit breastfeeding-safety discussion.
Establish who is caring for the infant right now, and how robust that arrangement is.
Screen substances, relationship, domestic abuse, finances and support.

Ask It Like This

"Having a new baby is a stressful time for a lot of women, how has it been for you?"
"Have you had any thoughts that frightened you, about yourself or the baby?"
"Who's with the baby at the moment?"
"Is there anything you've been planning to do?"

Risk

Suicide, which is a leading cause of maternal death: ask directly.
Harm to the infant, including through delusional belief, and risk of neglect.
Absconding to act on the delusional belief, and violence toward anyone who blocks that.
Safeguarding: notify the team, and be clear who holds the infant safely tonight.

Example Stations Covering This Theme

Postnatal Depression, Postpartum Psychosis.

Navigation

General Adult Psychiatry

Older Adults

Child and Adolescent Psychiatry

Learning Disability Psychiatry

Forensic Psychiatry

Addiction Psychiatry

Psychotherapy

Eating Disorder Psychiatry

Perinatal Psychiatry

General Adult Psychiatry

Eliciting psychotic phenomenology

60-Second Summary

In the Room

Spot It

Must Cover

Ask It Like This

Risk

Example Stations Covering This Theme

Explaining psychosis and antipsychotics to a family

60-Second Summary

In the Room

Spot It

Must Cover

Ask It Like This

Risk

Example Stations Covering This Theme

Antipsychotic side effects and physical health monitoring

60-Second Summary

In the Room

Spot It

Must Cover

Ask It Like This

Risk

Example Stations Covering This Theme

Depression: assessment and complex presentations

60-Second Summary

In the Room

Spot It

Must Cover

Ask It Like This

Risk

Example Stations Covering This Theme

Explaining physical treatments for mood disorder

60-Second Summary

In the Room

Spot It

Must Cover

Ask It Like This

Risk

Example Stations Covering This Theme

Mania and elevated mood

60-Second Summary

In the Room

Spot It

Must Cover

Ask It Like This

Risk

Example Stations Covering This Theme

The anxiety spectrum and obsessional disorders

60-Second Summary

In the Room

Spot It

Must Cover

Ask It Like This

Risk

Example Stations Covering This Theme

Self-harm, overdose and suicide risk

60-Second Summary

In the Room

Spot It

Must Cover

Ask It Like This

Risk

Example Stations Covering This Theme

Neuropsychiatry and functional presentations

60-Second Summary

In the Room

Spot It

Must Cover