The CASC is a structured clinical examination — and the most feared part of the MRCPsych for many candidates. This guide breaks down every station type with a structured framework you can apply on the day.
What is the MRCPsych CASC?
The CASC (Clinical Assessment of Skills and Competencies) is the clinical examination component of the MRCPsych. It consists of 16 stations over two circuits — 8 in each circuit. Each station is 7 minutes, with a 1-minute reading time per station.
Paired stations (where you see the same patient or scenario twice in sequence) add an extra layer of complexity — the second station usually requires you to manage or communicate something based on the first.
Important: The pass mark for CASC is set globally (not station by station), but you must not fall into a "near miss" on too many stations. Examiners score each station from 0–4 across structured criteria. There is no compensating for truly failing individual stations.
1. Mental State Examination (MSE) [High] 2–3 stations per sitting
The MSE is the backbone of the CASC. You will be asked to perform a mental state examination — covering appearance & behaviour, speech, mood, affect, thought, perception, cognition, and insight.
Structured Framework
✓ Appearance & behaviour: note dress, hygiene, psychomotor activity, eye contact, rapport
✓ Speech: rate, volume, tone, amount, fluency
✓ Mood: subjective ("how are you feeling?") and objective (observed affect)
✓ Thought: form (loosening, flight of ideas, thought block) and content (delusions, obsessions, overvalued ideas)
✓ Perception: hallucinations (modality, type, frequency, insight), illusions, depersonalisation
✓ Cognition: orientation, short-term memory, concentration (serial 7s), if needed — formal cognitive testing
✓ Insight: awareness of illness, willingness to accept treatment
💡 Pro tip: Do not rush through the MSE — the examiner is watching your structure. Name each domain out loud before exploring it. A missed domain is a missed mark.
2. History Taking [High] 2–3 stations per sitting
History stations require you to take a focused psychiatric history from a simulated patient or a collateral informant (family member, carer). These are often combined with risk assessment.
Structured Framework
✓ PC: presenting complaint in patient's own words
✓ HPC: onset, duration, progression, associated symptoms
✓ PMH: previous psychiatric diagnoses and admissions
✓ Medications: current, past, side effects, adherence
✓ FH: family history of psychiatric illness
✓ SH: living situation, relationships, occupation, stressors, substance use
✓ Developmental/premorbid history (for CAMHS or LD stations)
✓ Collateral: what does the informant tell you that the patient cannot?
💡 Pro tip: For collateral history stations, explicitly state what you are asking and why. Examiners look for systematic structure, not just information gathering.
3. Risk Assessment [High] At least 1–2 per sitting
Risk stations require you to assess risk of harm to self (suicide, self-harm) or harm to others. They often involve a complex presentation — recent attempt, expressed homicidal ideation, or safeguarding.
Structured Framework
✓ Ideation: passive thoughts vs. active suicidal ideation
✓ Intent: does the patient intend to act?
✓ Plan: specific method, access to means
✓ Previous attempts: number, intent, medical severity, rescue factor
✓ Protective factors: reasons for living, social support, religious beliefs
✓ Risk factors: mental illness, hopelessness (Beck Hopelessness Scale), recent losses, substance use, male sex, access to means
✓ Immediate management: is an admission required? Is the patient safe to go home?
💡 Pro tip: Never jump to management before completing the assessment. Examiners specifically mark candidates down for offering reassurance or discharge without a thorough risk formulation.
4. Mental Capacity Assessment [Medium] 1 per sitting
Capacity stations typically ask you to assess whether a specific patient has capacity to make a specific decision — usually refusing treatment. The Mental Capacity Act 2005 (England & Wales) underpins every answer.
Structured Framework
✓ Assume capacity: start by stating "I am assuming capacity unless shown otherwise"
✓ Understand: can the patient understand the information relevant to the decision?
✓ Retain: can they retain the information long enough to use it?
✓ Weigh/use: can they weigh up pros and cons and use that information?
✓ Communicate: can they communicate a decision (verbally, writing, gestures)?
✓ Document: a capacity assessment must be decision-specific and time-specific
💡 Pro tip: Always state the decision you are assessing capacity for at the start. A capacity assessment for "everything" is legally meaningless and will lose you marks.
5. Psychopharmacology Discussion [Medium] 1–2 per sitting
These stations require you to explain a medication or treatment to a patient or relative. Common scenarios: explaining clozapine, lithium, sodium valproate in pregnancy, ECT, or a new antipsychotic.
Structured Framework
✓ What the medication is (in lay terms)
✓ Why it is being recommended for this patient
✓ How it is taken (dose, frequency, route)
✓ Common side effects (top 3 the patient needs to know)
✓ Serious/rare side effects requiring urgent medical attention
✓ Monitoring requirements (blood tests, ECG, weights)
✓ Duration of treatment
✓ What happens if they stop suddenly
💡 Pro tip: Avoid medical jargon. Examiners are often simulating a patient who has minimal medical knowledge. Practise saying "white blood cell count" not "neutropenia". Smile — rapport is assessed.
6. Communication Skills [Medium] 1–2 per sitting
Communication stations test your ability to manage difficult conversations — breaking bad news, dealing with an angry relative, explaining a diagnosis, or discussing a sensitive situation.
Structured Framework
✓ Setting: privacy, sitting down, introduce yourself
✓ Establish what they already know: "What have you been told so far?"
✓ Elicit concerns: "What is worrying you most?"
✓ Clear and simple language: no jargon
✓ Acknowledge emotion: "That must be very difficult to hear"
✓ Chunk and check: deliver information in small pieces and verify understanding
✓ Offer a safety net: what to do if things get worse
💡 Pro tip: The SPIKES framework (Setting, Perception, Invitation, Knowledge, Empathy, Strategy) is excellent for breaking bad news. Know it cold.
7. Physical Examination [Low-Medium] 1 per sitting
Physical examination stations require a focused neurological or systemic examination — cerebellar examination, extrapyramidal side effects (EPSE), or a frontal lobe assessment. These are highly structured and predictable.
Structured Framework
✓ Introduce, gain consent, position patient appropriately
✓ State what you are looking for and why (e.g., "I am going to examine for signs of extrapyramidal side effects")
✓ Follow a systematic head-to-toe or specific-system approach
✓ Narrate as you examine: describe your findings out loud
✓ Summarise your findings at the end
💡 Pro tip: Practise these stations with a real partner. Reading about cerebellar examination is not the same as doing it. Know the EPSE components (rigidity, tremor, tardive dyskinesia, akathisia, dystonia) inside out.
► Practise all CASC stations on Psychgateway — interactive step-by-step dialogues, role player briefs and model answers for all 7 station types. Visit psychgateway.com/casc