Somatic symptom and related disorders OSCE — validation, function-first plan and safeguarding

Station objectives

1. Validate somatic symptoms as real and screen once for red flags, without over-investigating. [1] [2]
2. State the DSM-5 / DSM-5-TR principle (symptoms need not be medically unexplained) and reframe with the symptom-amplification model. [2]
3. Co-build a function-first interdisciplinary plan with functional goals, school reintegration and avoidance of opioid escalation. [4]
4. Establish conversion disorder on positive grounds and explain it without stigmatising language. [6]

Candidate brief

You are the general paediatric doctor in outpatient clinic / on the ward. You have 10 minutes for Station A (persistent symptoms, school absence, family wants more tests) and 12 minutes for Station B (functional leg weakness, positive Hoover sign, after exclusion of structural disease). Examiners score validation, safety, the DSM-5 principle, function-first framing and partnership language. [1] [3]

Station A — Persistent symptoms, school absence, family wants more tests

Setup: A 13-year-old with eight months of daily abdominal pain and headache, three normal scans and normal bloods, now attending school two days a week. The mother is distressed and convinced something is being missed. No current self-harm. [1]

Expected actions:

• Greet the young person first; secure time alone; state conditional confidentiality with its lawful limits. [3]
• Validate the symptoms as real and not her fault; elicit the family's explanatory model. [1]
• Take a biopsychosocial/HEEADSSS history (mood, sleep, school, peers, family, bullying, life events); screen for suicidality. [2]
• Screen once for red flags (weight loss, growth failure, neurological deficit, systemic features, nocturnal symptoms); state that further imaging is low-value without a new red flag. [1]
• State the DSM-5 principle: symptoms need not be medically unexplained; diagnose the positive pattern of disproportionate thoughts/behaviours. [2]
• Reframe the symptom-amplification loop and communicate the normal results as "reassuring — your body is healthy." [5]
• Co-build FUNCTION goals (school, sleep, movement, friends); coordinate psychology, physiotherapy, sleep work and a graded return to school. [4]
• Decline opioids clearly and empathically; treat comorbid mood. [1]

Station B — Functional leg weakness, positive Hoover sign

Setup: A 12-year-old on the ward with three weeks of functional left-leg weakness; a positive Hoover sign; targeted assessment has excluded structural neurological disease. She is using a wheelchair and has missed school. [6]

Expected actions:

• Validate that the symptoms are real; confirm the conversion disorder (functional neurological symptom disorder) diagnosis on positive grounds — symptoms incompatible with recognised disease — after targeted exclusion, not as a diagnosis of exhaustion. [6]
• Explain the limb changes as altered nervous-system processing, not new injury, avoiding stigmatising language. [2]
• Outline interdisciplinary management: functional physiotherapy (graded motor/sensory retraining), psychology (CBT/ACT), a sleep reset, and a graded return to function and school. [3]
• Screen for and treat comorbid anxiety and depression, which are common in childhood conversion disorder. [6]
• Set functional goals and a flare plan; name a coordinator. [4]

Marking anchors

Clear pass: validates symptoms as real; screens for red flags once and declines further testing without a new red flag; states the DSM-5 principle unprompted; reframes the symptom-amplification loop without stigmatising language; co-builds a function-first interdisciplinary plan with functional goals; treats school reintegration as a clinical outcome; declines opioids clearly and empathically; for Station B establishes conversion disorder on positive grounds. [1] [2] [4] [6] Borderline: validates well but defers school reintegration to "later," offers vague follow-up, avoids the opioid conversation, or labels conversion a "diagnosis of exclusion." Fail: dismisses symptoms as "stress"; promises more tests without red flags; prescribes opioids; sets a symptom-elimination goal; ignores school absence; uses stigmatising language; or misses a safeguarding concern. [1] [2]

Debrief pearls

• The explanation is itself a treatment — the symptom-amplification reframe, validated, changes the trajectory. [3]
• "Intentionality" separates factitious disorder (and fabricated/induced illness, a safeguarding pathway) from the unconscious SSRD family. [2]
• Function is the goal and the metric; school reintegration is a predictor of recovery. [4]