Psych CASC / OSCE · General adult psychiatry — personality disorders
Explain NPD formulation and treatment limits — CASC communication station
MRCPsych/FRANZCP-style communication station: explain pathological narcissism without stigma, outline frame and psychotherapy options, clarify medication limits, address suicide risk after shame, check understanding.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar in the outpatient clinic. [1]
Candidate instructions. Explain what narcissistic personality patterns mean in plain language without moral attack, outline why structured talking therapy and a clear therapeutic frame are central, clarify that medication does not cure NPD itself, address shame-related suicide risk after criticism, and check understanding. The examiner plays the patient. [1][2]
Candidate scenario
Your patient meets many NPD features with both status-focused grandiosity at work and private shame after criticism. There is no current plan to die, but she had passive death wishes after the review. You plan a structured psychotherapy referral (psychodynamic/TFP-informed or schema-informed where available) with clear boundaries, plus assessment for depression. [1][3]
Marking domains
- Empathy, structure and agenda-setting (including her fear of the label)
- Non-stigmatising explanation of pathological narcissism as self-esteem and relationship pattern
- Clear therapy plan and importance of consistent frame
- Accurate medication expectations (not disease-modifying for NPD; treat depression if present)
- Safety-netting after shame/criticism crises
- Checks understanding [2][3]
Reveal assessor key
Open and agenda-set. Name time; ask what the label means to her (evil, untreatable, personality attack). [1]
Explain diagnosis. "When we talk about narcissistic personality patterns, we mean a long-term difficulty regulating self-esteem — sometimes looking confident or entitled on the outside, and very shame-sensitive underneath. It can make criticism feel catastrophic and relationships become about status or admiration. It is a recognised clinical pattern, not a moral verdict that you are a bad person, and people can make meaningful changes with the right structured help." [1][3]
Explain treatment. Main work is structured talking therapy with clear goals and boundaries, focusing on how shame, rage and relationships play out — including in therapy. Medication does not rewrite personality; we use medicines mainly if there is depression or another illness, with careful review — not as a lifelong cocktail for 'narcissism.' [1][3]
Safety. After public criticism or humiliation, some people feel they cannot go on. Make a plan for those moments: who to call, crisis contacts, reducing access to means, early review if death wishes return. [2]
Close. Summarise, teach-back, written information, follow-up, realistic hope without promising instant cure. [1][3]
References
- [1]Caligor E, Levy KN, Yeomans FE Narcissistic personality disorder: diagnostic and clinical challenges Am J Psychiatry, 2015.PMID 25930131
- [2]Gabbard GO Narcissism and suicide risk Ann Gen Psychiatry, 2022.PMID 35065658
- [3]Crisp H, Gabbard GO Principles of Psychodynamic Treatment for Patients With Narcissistic Personality Disorder J Pers Disord, 2020.PMID 32186987