Psych CASC / OSCE · General adult psychiatry — factitious disorder and malingering
Explain suspected factitious behaviour and a non-collusive plan — CASC communication station
MRCPsych/FRANZCP-style communication station: maintain alliance without collusion, explain concerns factually, outline coordinated care, offer psychiatric support, address capacity/self-discharge, and safety-net mood risk.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar on the medical ward.[1]
Candidate instructions. Engage respectfully; do not collude with a false diabetes narrative; explain the team’s safety concerns using facts; outline a coordinated plan that still offers care; assess mood and self-discharge risks; avoid humiliation; check understanding and safety-net.[1][2][4]
Candidate scenario
Your patient has recurrent hypoglycaemia. Insulin syringes were found. They want you to force physicians to reverse their concerns and write that this is ordinary diabetes. Your job is honest, non-punitive communication and a workable plan.[3][4]
Actor notes (examiner plays patient)
- Angry, ashamed, fear of being labelled "crazy" or criminal.
- Alternates between denial and partial admission if candidate is calm and factual.
- If candidate colludes ("yes, tell them it's definitely type 1"), becomes triumphant — mark fail for collusion.
- If candidate is contemptuous, shuts down and self-discharges angrily.
- Admits low mood when asked gently; no active suicide plan. Pattern reflects C-L factitious presentations where alliance and honesty must coexist.[3][4]
Domains assessed
- Empathy without collusion.[1]
- Clear explanation of medical safety concerns and inconsistencies.[1][3]
- Multidisciplinary non-collusive plan and limits on unnecessary procedures.[1][2]
- Offer of psychiatric support for distress/depression without forced confession.[2]
- Capacity-informed discussion of self-discharge and safety-netting.[1]
Model communication points
Reveal example phrases
- "I can see this is frightening and embarrassing. My job is to be honest and still help you stay safe."[1]
- "The team is worried because the pattern of low sugars and the syringes do not fit ordinary diabetes alone. We need to stop further harm, including unnecessary procedures."[3]
- "I will not write that this is simply ordinary diabetes if that is not what the evidence shows. False certificates help no one and can cause more harm."[1]
- "We would like one coordinated plan with your physicians and GP, fewer redundant tests, and support for the distress and low mood you are carrying."[2][4]
- "You do not have to confess anything today to receive respectful care. We can still treat infection risk, monitor sugars safely, and offer mental health follow-up."[2]
- "If you leave, let us talk through the medical risks of untreated hypoglycaemia and how to get urgent help. I also want to check whether you feel unsafe in your mood."[1]
Examiner scoring cues
Pass: calm, factual, non-collusive, offers ongoing care, checks mood and understanding, clear follow-up.
Borderline: accurate but overly legalistic or cold.
Fail: colludes with false diagnosis; humiliates patient; ignores medical risk; forces confession as condition of care; no safety-net.[1][2]
References
- [1]Bass C, Halligan P Factitious disorders and malingering: challenges for clinical assessment and management Lancet, 2014.PMID 24612861
- [2]Eastwood S, Bisson JI Management of factitious disorders: a systematic review Psychother Psychosom, 2008.PMID 18418027
- [3]Krahn LE, Li H, O'Connor MK Patients who strive to be ill: factitious disorder with physical symptoms Am J Psychiatry, 2003.PMID 12777276
- [4]Margolis M, Wong TL, Shmuts R, Taylor JB Consultation-Liaison Case Conference: A Case of Factitious Disorder Imposed on Self J Acad Consult Liaison Psychiatry, 2023.PMID 37499871