Psych CASC / OSCE · Intellectual disability psychiatry
Explain dual diagnosis and psychotropic review to carers — CASC communication station
MRCPsych/FRANZCP-style communication station: explain diagnostic overshadowing without jargon overload, modified presentation, medical checks, DC-LD-adapted thinking in plain language, and evidence-based psychotropic caution with collaborative review.
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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 intellectual disability clinic. [1]
Candidate instructions. Explain to the carers that new self-injury may reflect mental or physical illness rather than "just intellectual disability", outline the assessment plan, discuss why long-term risperidone needs review, and agree a collaborative plan. Avoid jargon; check understanding; do not invent legal section numbers. [2]
Candidate scenario
Your patient has moderate intellectual disability and limited speech. Over 6 weeks he has been hitting his head, refusing favourite activities, and waking early. Carers believe this is inevitable. He has taken risperidone 2 mg at night for 3 years "for behaviour" without a clear mental illness diagnosis or recent review. They ask: "Are you saying we failed him? Will taking away the tablet make him dangerous? Can people like him even get depression?" [1][2]
Marking domains
- Empathy, structure, no blame of carers
- Plain-language explanation that mental illness is common and change from baseline matters (not "just ID")
- Medical checks first (pain, constipation, dental, infection)
- Explanation of adapted assessment and collateral
- Risperidone review rationale without abrupt unsafe stop scare tactics; monitoring and support plan
- Behaviour support and multiagency follow-up
- Checks understanding; safety-netting [2][3][4][5]
Reveal assessor key
Open. Thank carers; name the time; ask main worries first. Explicitly validate their hard work — this is not parental/carer failure.[2]
Dual diagnosis in plain language. "People with intellectual disability get depression, anxiety and other mental health problems more often than many realise. When someone cannot easily say how they feel, illness can show up as new behaviour — hitting, withdrawing, sleep change. We never assume it is only the disability."[1][2]
Assessment. Physical checks for pain and constipation/dental problems first; talk to people who know his baseline; look at what changed in his environment; consider mental health with adapted tools. Support decision-making for any treatment choices.[2][5]
Medicines. "Risperidone can help some people when there is a clear reason, but large studies show these medicines are used more often than mental illness is recorded, and one major trial found tablets were not better than placebo for aggression alone. We will not stop anything suddenly if that is unsafe; we will review why it was started, check side-effects (weight, movement, blood tests), and only change the dose with a plan and support."[3][4][5]
What helps. Consistent routines, behaviour support plan, treating any depression if present, carer support, clinic follow-up.[5]
Close. Summarise, invite questions, crisis contacts if self-injury escalates, written plan and review date. [2]
References
- [1]Cooper SA, Smiley E, Morrison J, Williamson A, Allan L Mental ill-health in adults with intellectual disabilities: prevalence and associated factors Br J Psychiatry, 2007.PMID 17197653
- [2]Ali A, Hassiotis A Illness in people with intellectual disabilities BMJ, 2008.PMID 18340045
- [3]Tyrer P, Oliver-Africano PC, Ahmed Z, et al. Risperidone, haloperidol, and placebo in the treatment of aggressive challenging behaviour in patients with intellectual disability: a randomised controlled trial Lancet, 2008.PMID 18177776
- [4]Sheehan R, Hassiotis A, Walters K, Osborn D, Strydom A, Horsfall L Mental illness, challenging behaviour, and psychotropic drug prescribing in people with intellectual disability: UK population based cohort study BMJ, 2015.PMID 26330451
- [5]Deb S, Kwok H, Bertelli M, et al. International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities World Psychiatry, 2009.PMID 19812757