Psych CASC / OSCE · Old age psychiatry — grief and loss
Explain late-life bereavement and prolonged grief to family — CASC communication station
MRCPsych/FRANZCP-style communication station: explain adaptive grief vs PGD vs MDD, duration clocks, CGT, avoid long-term benzodiazepines, suicide safety, practical supports.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the old-age psychiatry registrar in outpatient clinic. [1]
Candidate instructions. Explain in plain language the difference between normal grief and prolonged grief disorder; address fear that this is dementia or "going mad"; outline grief-focused psychological treatment (CGT evidence in older adults); explain that long-term sleeping tablets are not the treatment; discuss depression screening and suicide safety; outline practical supports and follow-up; check understanding. Examiner plays the daughter. [1][2][5]
Candidate scenario
Your patient is an 80-year-old man 14 months after his wife's death. He still sets two places, avoids their bedroom, has withdrawn from friends, and says life is empty. Cognitive screen is grossly intact; he is not delirious. Working diagnosis: prolonged grief disorder. Plan: CGT-informed grief-focused therapy, practical supports, safety planning, screen and treat depression if full criteria emerge, no standing benzodiazepine. Daughter is frightened and asks for diazepam "to knock him out so he can sleep." [1][2][5]
Marking domains
- Empathy, structure, and shared agenda with the daughter
- Accurate plain-language explanation of adaptive grief vs PGD vs MDD/dementia
- Clear plan: grief-focused psychotherapy first for PGD
- Explains limited role of medicines and avoids promoting long-term benzodiazepines
- Safety, practical supports, teach-back, and follow-up [1][3][4]
Reveal assessor key
Open and agenda-set. Greet; ask main worries first (dementia? will he kill himself? sleeping tablet request). Name time available. [5]
Explain diagnosis. "After someone we love dies, grief is normal — waves of missing them that usually ease enough for life to restart. A smaller group stay stuck more than a year later with intense longing, avoiding reminders, and unable to rebuild routines. We call that prolonged grief disorder. It is not the same as Alzheimer disease progressing overnight, and it is not 'going mad.' We also carefully check for depression, which can happen during grief and is treatable in its own right." [2][3][5]
Explain treatment. "The best evidence for stuck grief is a structured talking treatment — Complicated Grief Treatment or similar grief-focused CBT — which has been studied specifically in older adults and works better than general supportive counselling styles. We also fix practical problems: meals, isolation, finances, getting him back into safe social contact. Medicines are for clear depression or short-term severe insomnia with an exit plan — not as a long-term 'knock-out' for yearning." [1][4]
Safety and close. "We always ask carefully about suicide, especially in older people living alone after losing a partner, and we reduce access to dangerous means. We will review him around hard dates like anniversaries." Summarise, teach-back, invite questions, written information, next review. [4][5]
References
- [1]Shear MK, Wang Y, Skritskaya N, et al. Treatment of complicated grief in elderly persons: a randomized clinical trial JAMA Psychiatry, 2014.PMID 25250737
- [2]Prigerson HG, Horowitz MJ, Jacobs SC, et al. Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11 PLoS Med, 2009.PMID 19652695
- [3]Kendler KS, Myers J, Zisook S Does bereavement-related major depression differ from major depression associated with other stressful life events? Am J Psychiatry, 2008.PMID 18708488
- [4]Stroebe M, Schut H, Stroebe W Health outcomes of bereavement Lancet, 2007.PMID 18068517
- [5]Simon NM, Shear MK, Reynolds CF, et al. Commentary on evidence in support of a grief-related condition as a DSM diagnosis Depress Anxiety, 2020.PMID 31916663