PUID: 64 || PLAB 2 Mock 1 :: PsychMiscOwn6: OCD (1st Attempt)

Practice a case with the AI patient 🤖

Summary

This PLAB 2 psychiatric station focuses on assessing a patient presenting with symptoms suggestive of Obsessive Compulsive Disorder (OCD), particularly intrusive thoughts and compulsive behaviours affecting work, studying, and daily functioning. The consultation tests the candidate’s ability to conduct a structured psychiatric assessment, identify red flags, explore ICE (Ideas, Concerns, Expectations), assess functional impairment, and formulate an empathetic management plan.

The examiner emphasized that this is not simply about diagnosing OCD, but understanding how the symptoms impact the patient’s life, studies, emotional wellbeing, and functioning. Strong patient-centred communication and logical consultation structure are essential.

Key Points

Understanding OCD

• OCD stands for Obsessive Compulsive Disorder

• Characterized by:

  • Obsessions → intrusive repetitive thoughts

  • Compulsions → repetitive actions performed to reduce anxiety

• Symptoms become clinically significant when they:

  • Cause distress

  • Affect work/studies

  • Interfere with relationships or daily activities

  • Consume significant time

Common Obsessions

• Fear of contamination/germs

• Fear of harm

• Fear of making mistakes

• Doubts (e.g., “Did I lock the door?”)

Common Compulsions

• Excessive hand washing

• Repeated checking

• Reassurance seeking

• Repeating rituals

• Arranging items symmetrically

The examiner highlighted that OCD is relatively common, especially among medical students and high-achieving individuals. Reassurance that patients are “not going crazy” can significantly reduce anxiety and build rapport.

Important Psychiatric Concepts

Ego-Dystonic Nature of OCD

OCD is an ego-dystonic disorder, meaning:

• Patients recognize thoughts as irrational

• Thoughts cause distress

• Patients try to resist them

Example:

“I know I locked the door, but I still feel compelled to check again.”

This differentiates OCD from obsessive-compulsive personality traits.

Obsessive Compulsive Personality Disorder (OCPD)

• More perfectionistic traits

• Ego-syntonic

• Behaviours feel acceptable to the patient

• No intrusive distressing thoughts

Understanding this distinction is important in psychiatric stations.

History Taking in OCD Stations

Opening the Consultation

Important examiner tip:

• Confirm:

  • Full name

  • Age

• Use open-ended questions

Example:

“Can you tell me what has been happening recently?”

OR

“I understand you’ve been struggling to complete your work. Would you like to tell me more about that?”

This demonstrates:

• Patient-centred care

• Efficient consultation structure

• Use of candidate instructions intelligently

Exploring Obsessions

Ask about:

• Intrusive repetitive thoughts

• Contamination fears

• Fear of mistakes

• Harm-related thoughts

• Triggering situations

Questions:

• “Do you get repeated thoughts you cannot ignore?”

• “What worries you the most?”

• “What happens if you try not to do the action?”

Exploring Compulsions

Quantify compulsive behaviours:

• Frequency

• Duration

• Severity

• Trigger factors

Examples:

• Handwashing frequency

• Door checking

• Repeating actions

• Cleaning rituals

Important examiner advice:

• Ask what happens if the patient resists the compulsion

• Assess level of distress and anxiety

Functional Impact Assessment

Very important scoring area in PLAB 2.

Assess impact on:

• Studies

• Work

• Sleep

• Concentration

• Social interactions

• Daily activities

The patient’s major concern in this station was inability to complete work/studies. Candidates must identify and address this specifically.

ICE (Ideas, Concerns, Expectations)

The examiner strongly emphasized ICE.

Ideas

Explore what the patient thinks is happening.

Examples:

• “Do you have any thoughts about what might be causing this?”

• “Were you worried this could mean something serious?”

Patients may fear:

• “I’m going crazy”

• Dementia

• Losing control

Correct misconceptions gently.

Concerns

Understand the patient’s biggest worry.

In this case:

• Academic impairment

• Inability to complete work

• Fear of failure

Expectations

Explore what help the patient wants.

Examples:

• Support letter

• Sick note

• Academic accommodations

• Treatment options

This helps create a patient-centred management plan.

Risk Assessment

Always rule out psychiatric red flags.

Assess:

• Depression

• Low mood

• Anhedonia

• Suicidal thoughts

• Self-harm

• Psychosis

The examiner praised ruling out:

• Psychosis

• Self-harm

• Depression symptoms

Psychiatric stations require safe practice first.

Diagnostic Approach

Step-by-Step PLAB 2 Approach

1. Introduction

• Introduce yourself

• Confirm patient identifiers

• Establish rapport

2. Open Exploration

• Explore presenting complaint

• Clarify symptoms

3. Assess Obsessions

• Intrusive thoughts

• Triggers

• Distress level

4. Assess Compulsions

• Behaviours

• Frequency

• Duration

• Resistance attempts

5. Assess Functional Impact

• Work/studies

• Sleep

• Relationships

• Daily functioning

6. ICE

• Ideas

• Concerns

• Expectations

7. Risk Assessment

• Suicide/self-harm

• Depression

• Psychosis

8. Past Psychiatric History

• Previous episodes

• Treatment history

• Counselling/medication

9. Social History

• Academic pressures

• Family support

• Stressors

10. Summarise and Explain

• Provide likely diagnosis

• Reassure appropriately

• Discuss management

Management

Immediate Management

Psychoeducation

Explain:

• OCD is common

• It is treatable

• Patient is not “crazy”

• Symptoms can improve significantly

Psychological Treatment

First-Line:

Cognitive Behavioural Therapy (CBT)

Particularly:

• Exposure and Response Prevention (ERP)

Examples:

• Gradual exposure to triggers

• Avoiding compulsive response

Medication

SSRIs

Examples:

• Fluoxetine

• Sertraline

• Fluvoxamine

Explain:

• Delayed onset of benefit

• Need for adherence

• Possible side effects

Functional Support

Address practical concerns:

• Sick note if appropriate

• University support

• Occupational adjustments

• Academic accommodations

The examiner specifically emphasized addressing the patient’s concern about studies/work impairment.

Safety Netting

Advise patient to seek urgent help if:

• Suicidal thoughts develop

• Symptoms worsen significantly

• Unable to function

• Severe depression develops

Communication Skills

Important PLAB 2 Communication Points

Avoid Stock Phrases

Examiners dislike rehearsed communication.

Avoid repeatedly saying:

• “Is that okay?”

• “Bear with me”

• “May I ask personal questions?”

Use natural conversation instead.

Demonstrate Active Listening

• Listen carefully

• Follow patient cues

• Explore clues given by patient

The examiner emphasized:

Every patient statement contains clues.

Use Empathy Naturally

Good empathy:

• “That sounds very distressing.”

• “I can understand how this is affecting your studies.”

Avoid exaggerated or artificial empathy.

Signposting

Useful examples:

• “I’d like to ask a few questions about how this affects daily life.”

• “Can we talk a bit about your mood?”

This improves consultation structure.

Ethical Considerations

Confidentiality

Maintain confidentiality appropriately without overusing scripted statements.

Capacity and Insight

Patients with OCD generally retain:

• Insight

• Capacity

• Decision-making ability

Patient-Centred Care

Important GMC principles include:

• Respecting patient dignity

• Shared decision making

• Supporting informed choices

• Clear communication

• Compassionate care

Examiner Tips for PLAB 2 OCD Stations

What Examiners Want to See

• Structured consultation

• Logical questioning

• Functional assessment

• ICE exploration

• Risk assessment

• Patient-centred management

Common Mistakes

• Missing ICE

• Not assessing function

• Over-rehearsed communication

• Ignoring patient concerns

• Poor time management

• Failing to explore compulsions properly

Time Management Tips

• Use focused psychiatric history

• Avoid unnecessary details

• Address patient concerns early

• Move efficiently to management

Additional Resources

Useful guidance:

• GMC Good Medical Practice

• GMC PLAB Examiner Top Tips

• GMC Common OSCE Errors Guide

• NICE Guidelines for OCD

• CBT and ERP principles