Psych CASC / OSCE · General adult psychiatry — feeding and eating disorders
Explain rumination disorder and diaphragmatic breathing to a patient — CASC communication station
MRCPsych/FRANZCP-style communication station: explain rumination mechanism, discrimination from BN/GORD, breathing training, baclofen as possible later adjunct, and safety-netting.
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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 a liaison / eating disorders clinic. [5]
Candidate instructions. Explain rumination disorder in plain language, how it differs from reflux and from bulimia nervosa, teach the rationale for diaphragmatic breathing, give a balanced answer on medication, and safety-net. Check understanding and invite questions. The examiner plays the patient. [1][2]
Candidate scenario
The patient has effortless post-meal regurgitation for 18 months, often reswallows, has no fear of fatness, normal endoscopy, and failed PPIs. The plan is education and diaphragmatic breathing with dietetic support; biofeedback if available; baclofen only if refractory under specialist review. The patient fears “this means I have an eating disorder like bulimia” and asks for a tablet today. [1][2][3][4]
Marking domains
- Empathy, structure, non-stigmatising language
- Accurate plain-language model (effortless regurgitation; muscle pattern after meals)
- Clear discrimination from bulimia nervosa and from acid reflux
- Diaphragmatic breathing rationale and brief how-to / practice expectation
- Medication: not first-line cure; baclofen possible later if needed, with side-effect honesty
- Safety-net (weight loss, dehydration, blood in vomit, severe pain) and collaboration with GI
- Teach-back [1][2][3][5]
Reveal assessor key
Open and agenda-set. Thank patient; name time; ask top worries (bulimia label, tablet, work embarrassment). [5]
Explain rumination. “This is rumination disorder — after eating, the muscles of the belly and chest can push food back up effortlessly. Many people rechew or reswallow. It is a real, treatable pattern — not you being dramatic.” [1][2]
Vs reflux and bulimia. “Reflux is more about acid and heartburn and often improves with acid tablets — yours did not, and the timing and effortless pattern fit rumination. Bulimia involves binge eating and bringing food up to control weight or shape. You have told us that is not your driver, so we are not treating this as bulimia.” [1][5]
Breathing treatment. Teach diaphragmatic breathing as a competing skill after meals so the strain pattern does not push food up; daily practice; optional biofeedback if available (evidence supports it).[2][4]
Medication. No tablet is first-line alone. If breathing work is not enough, specialists sometimes use baclofen (evidence from a randomised trial) with monitoring for sleepiness and other effects — that is a later step, not today’s sole fix.[3]
Close. Summarise, teach-back, written information, when to seek urgent care (fainting, severe pain, blood, rapid weight loss). Offer follow-up and GI liaison. [1][5]
References
- [1]Halland M, Pandolfino J, Barba E Diagnosis and Treatment of Rumination Syndrome Clin Gastroenterol Hepatol, 2018.PMID 29902642
- [2]Halland M, Parthasarathy G, Bharucha AE, Katzka DA Diaphragmatic breathing for rumination syndrome: efficacy and mechanisms of action Neurogastroenterol Motil, 2016.PMID 26661735
- [3]Pauwels A, Broers C, Van Houtte B, et al. A Randomized Double-Blind, Placebo-Controlled, Cross-Over Study Using Baclofen in the Treatment of Rumination Syndrome Am J Gastroenterol, 2018.PMID 29206813
- [4]Barba E, Accarino A, Soldevilla A, Malagelada JR, Azpiroz F Randomized, Placebo-Controlled Trial of Biofeedback for the Treatment of Rumination Am J Gastroenterol, 2016.PMID 27185077
- [5]Crone C, Fochtmann LJ, Attia E, et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders Am J Psychiatry, 2023.PMID 36722117