Psych CASC / OSCE · General adult psychiatry — mood disorders / women's mental health
Explain PMDD, diary confirmation and intermittent SSRI options — CASC communication station
MRCPsych/FRANZCP-style communication station: explain PMDD, prospective diary, continuous vs luteal SSRI dosing with a named regimen, suicide safety-netting, and when COC or specialist escalation is considered.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes after reading. You are the psychiatry registrar in outpatient clinic. [4]
Candidate instructions. Explain PMDD in plain language, justify two-cycle prospective ratings, offer an SSRI plan with continuous or luteal-phase options using a named drug and dose, address passive death wishes with a safety plan, check understanding, and outline when to seek urgent help. The examiner plays the patient. [1][4]
Candidate scenario
History suggests pure PMDD with follicular remission. She has not completed a formal diary. She is open to medication but fears "being on antidepressants forever." Passive death wishes recur three days before menses without plan or intent. No mania history. She is not seeking pregnancy this year. You plan fluoxetine 20 mg orally daily continuous as default, with luteal-phase-only as a negotiated alternative after explaining trade-offs. [2][3]
Marking domains
- Empathy, structure, agenda-setting
- Accurate plain-language distinction of PMDD from mild PMS and from continuous depression
- Clear explanation of prospective diary for two cycles
- Named SSRI with dose and continuous vs luteal rationale
- Suicide safety-netting linked to luteal phase
- Shared decision-making and teach-back [1][2][4]
Reveal assessor key
Open. Name time; ask priorities (diagnosis legitimacy, diary burden, medication duration, safety). [4]
Explain PMDD. "This is more than ordinary PMS. Premenstrual dysphoric disorder means severe mood symptoms — irritability, mood swings, anxiety or low mood — that appear in the days before your period, ease soon after bleeding starts, and significantly disrupt life. Hormone blood levels are often normal because the issue is how the brain responds to normal cycle changes, not 'too little hormone' on a blood test." [1]
Diary. "Guidelines ask for daily symptom tracking over about two cycles so we confirm the timing pattern. We can still start help now if you are struggling; the diary makes the diagnosis solid and shows whether treatment is working." [1]
SSRI options. "An SSRI such as fluoxetine 20 mg each morning is first-line evidence-based treatment. Many people take it every day. Because benefit can start within days in PMDD, some take it only from mid-cycle until the period starts. Daily dosing is a bit more reliable in research overall; half-cycle dosing can reduce tablet days if your cycles are regular. Side-effects can include nausea or sexual changes; contact us the same day if suicidal thoughts worsen after starting." [2][3]
Risk. Acknowledge passive death wishes; collaborative safety plan for late luteal days; crisis contacts; early review if intent forms; do not minimise as 'just hormones'. [4]
Close. Summarise choices, provide diary template, book review, teach-back. Mention CBT and, if contraception is desired later, specialised pill options without overwhelming detail. [3][4]
References
- [1]Epperson CN, Steiner M, Hartlage SA, et al. Premenstrual dysphoric disorder: evidence for a new category for DSM-5 Am J Psychiatry, 2012.PMID 22764360
- [2]Steiner M, Steinberg S, Stewart D, et al. Fluoxetine in the treatment of premenstrual dysphoria N Engl J Med, 1995.PMID 7739706
- [3]Jespersen C, Lauritsen MP, Frokjaer VG, Schroll JB Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder Cochrane Database Syst Rev, 2024.PMID 39140320
- [4]Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391