Compulsive Tidying — Free SCA Practice Case
Teenager with compulsive tidying
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Leo Baxter
Age
16 years
Consultation Type
VideoAge
16
Reason for Encounter
"Patient requested an appointment. He states he cannot stop tidying his bedroom, it takes hours every night, and it is causing him to fail his GCSE mock exams."
Medical Records
- ●PMH: Childhood asthma (resolved).
- ●Medications: None.
- ●Allergies: NKDA.
Recent Notes
- ●14 months ago: Mother diagnosed with breast cancer. Underwent surgery and chemotherapy.
Patient Script
For the friend playing the patient role
Character Overview: You are Leo. You are 16 years old and in your final year of GCSEs. You are utterly exhausted, having barely slept for weeks. You are deeply embarrassed by your behaviour but feel completely trapped by it. Every night, you spend 3 to 4 hours perfectly aligning everything in your room—books, pens, shoes, clothes. You are hiding a terrifying, irrational thought (magical thinking). You believe that if your room is not perfectly symmetrical and organized before you go to sleep, your mum's cancer will come back and she will die. You know logically that this makes no sense, which makes you feel "crazy," but the anxiety of not doing it is so physically overwhelming you feel like your chest will explode. You will not volunteer the fear about your mum's cancer unless the doctor specifically asks why you tidy, what thoughts go through your head when you try to stop, or explores your underlying worries.
Consultation Flow & Responses:
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The Opening
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If the doctor asks an open question: "Hi Doctor. I really need some help. I think there is something wrong with my brain. I spend hours every single night organizing my room. If I don't get it perfect, I get this horrible tight feeling in my chest. I'm failing my mocks because I'm up until all hours lining up my books instead of revising."
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Data Gathering (The Layers)
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Layer 1: The Compulsion (The Behaviour):
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"Everything has to be parallel. My pens have to be spaced exactly an inch apart. My clothes have to be color-coded and folded in exact squares."
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"If I bump the desk and a pen rolls, I have to start the whole routine from the beginning."
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Layer 2: The Impact & Attempts to Stop:
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"I'm so tired I keep falling asleep in maths. My friends have stopped asking me to hang out because I just go home to fix my room."
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"I've tried to just leave it messy, but the panic builds up in my throat until I'm shaking. I have to do it to make the panic stop."
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Layer 3: The Core Revelation (The Obsession/Magical Thinking) — ONLY REVEAL IF ASKED:
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If the doctor asks: "What do you think will happen if you don't tidy it?" or "Are you worried about something specific happening?"
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Reaction (The Reveal): You look down, incredibly ashamed, and your voice cracks. "It's about my mum. Since she got the all-clear from her cancer, my brain keeps telling me that if my room isn't perfectly symmetrical, her cancer will come back and it'll be my fault. I know it sounds completely insane. Books on a desk can't cause cancer. But what if I'm wrong? I can't risk it, Doctor. I just can't."
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Layer 4: Risk Screen (Mood & Harm):
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If asked about feeling low or self-harm: "I feel miserable because I'm so tired, but I don't want to hurt myself. I just want my brain to be quiet so I can sleep."
ICE — Ideas, Concerns, Expectations
Actor guidance: Leo does not volunteer these unprompted. These surface only when the candidate directly explores the patient's perspective.
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Ideas: Leo thinks there is something fundamentally wrong with his brain — he cannot explain why he cannot stop, and the closest label he can think of is that he is "going crazy" or "losing it." He does not know what OCD is by name. If asked directly what he thinks is going on, he says: "I honestly don't know. I just think my brain is broken. Normal people don't do this, do they?"
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Concerns: His deepest fear is twofold. On the surface, he is terrified that this behaviour means he is developing a serious mental illness — "I looked it up and some of the stuff online said schizophrenia, and that scared me even more." Beneath that, he is terrified that if he stops the rituals, his mum will get ill again. He is also acutely worried about his GCSEs — "If I fail my mocks, I won't get into sixth form, and then what?"
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Expectations: He wants someone to tell him he is not "crazy" and to give him a way to stop the rituals so he can sleep and revise. He is not expecting medication — he is hoping there is some kind of technique or therapy. If asked what he is hoping for from today: "I just need someone to help me stop doing this. I can't carry on like this — I'm wrecked."
If Asked — Medical History and Medications
Actor guidance: Leo has minimal medical history. The following covers what a candidate is likely to ask about.
- ●If asked about asthma: "I had it when I was little — like primary school age. I don't have an inhaler anymore. It just sort of went away. It's got nothing to do with this."
- ●If asked about any current medications: "No, I'm not on anything. I've never taken anything regularly."
- ●If asked about allergies: "No, nothing that I know of."
- ●If asked about family mental health history: "I don't think so. My mum had a really tough time during chemo — she was crying a lot and not sleeping — but I don't know if she saw anyone for it. We don't really talk about stuff like that at home."
- ●If asked about his mum's cancer in more detail: "She found a lump about a year ago. She had an operation and then chemo. It was horrible — she lost all her hair and was sick all the time. But the doctors said she's in remission now, so she's doing okay. The tidying thing started properly after she finished treatment, I think."
Social History and Lifestyle Impact
Actor guidance: Leo shares this naturally in conversation when discussing the impact on his life. He does not deliver it as a list.
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Occupation / daily life context: Leo is a Year 11 student studying for his GCSEs. He used to play football for the school team on Wednesdays and Saturdays but has stopped going to training because he cannot get his room sorted in time. He lives with his mum and younger sister (age 12). His parents separated when he was 10 and he sees his dad some weekends, but his dad does not know about the tidying.
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Lifestyle impact of the condition: The disruption is severe and escalating. "I used to be in the top set for everything. Now my teachers are emailing my mum saying I'm not handing in coursework. I literally can't start revising until the room is done, and by then it's the middle of the night and I just crash." He has also stopped going to football: "I missed the last four training sessions. Coach asked if everything was alright and I just said I was ill. I can't exactly tell him I'm at home lining up my shoes." His friendships are suffering: "My mates think I'm being weird. They've stopped texting me to come out. I just sit in my room doing... this." He feels isolated and ashamed — he has not told anyone about the rituals, including his mum and his friends.
If Asked — Associated Symptoms
Actor guidance: Leo responds to direct questions about these symptoms naturally and briefly. He does not volunteer this information.
- ●If asked about other rituals or compulsions beyond tidying: "I do check the front door is locked a few times before bed, but that only takes a minute — it's not like the room thing. That's the main one that's ruining everything."
- ●If asked about intrusive or unwanted thoughts beyond the magical thinking: "No, it's really just the thing about my mum. I don't get horrible thoughts about hurting people or anything like that."
- ●If asked about handwashing or contamination worries: "No, nothing like that. I'm not bothered about germs or anything."
- ●If asked about appetite or weight changes: "I'm not really eating properly — I just grab whatever. I've probably lost a bit of weight but I haven't weighed myself. I'm just not that hungry when I'm this tired."
- ●If asked about concentration: "It's terrible. I can't focus on anything at school. My brain is just full of whether I left something out of place."
- ●If asked about anxiety symptoms beyond the rituals (e.g. generalised worry, social anxiety): "I'm not anxious about other stuff, not really. It's all about the room and my mum. I'm not scared of going to school or talking to people or anything like that."
- ●If asked about panic attacks: "I don't get proper panic attacks out of nowhere. The panic only comes when I try to stop tidying or when I think something is out of place."
- ●If asked about sleep in more detail: "I'm getting maybe four or five hours a night. I can't fall asleep until the room is done. Even then I sometimes wake up and check things again. I'm absolutely shattered."
- ●If asked about substance use (alcohol, drugs, vaping): "No, I don't drink or do drugs. I vaped a bit last year with my mates but I stopped. It's not really my thing."
- ●If asked about tics or involuntary movements: "No, nothing like that."
- ●If asked about hallucinations (hearing or seeing things): "No, I don't hear voices or see things. It's just the thoughts that won't stop."
Negotiation & Collaborative Management Plan
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If the Doctor just tells you to "try leaving one thing out of place":
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Reaction: Highly anxious. "I can't just do that on my own! I told you, I start shaking. If I do that, who guarantees my mum won't get sick?" (Testing the doctor's understanding that he needs structured therapy, not just casual advice).
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If the Doctor validates the "magical thinking" as a normal part of OCD:
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Reaction: Massive relief. "Wait, really? Other people get thoughts like that? I honestly thought I was developing schizophrenia or something."
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If the Doctor suggests starting medication (Antidepressants/SSRIs) immediately today:
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Reaction: Resistant. "I don't want to take brain pills. Won't they turn me into a zombie? Can't I just talk to someone first?"
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If the Doctor explains CBT and ERP (Exposure and Response Prevention):
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Reaction: "So a therapist would actually help me sit with the panic until it goes away, without me having to tidy? That sounds terrifying, but if it works, I'll do it."
Safety Netting / Follow-up
- ●If the Doctor asks to bring his mum in next time:
- ●Reaction: "I haven't told her because I didn't want to remind her about the cancer, but if you think it will help to have her support with the therapy, I'll tell her tonight."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Recognising OCD and the Core Cycle
- ●Obsessive-Compulsive Disorder (OCD) is characterised by intrusive, unwanted obsessions that generate intense anxiety, and compulsions performed to neutralise that anxiety — providing only temporary relief, which reinforces the cycle and perpetuates the disorder.
- ●Obsessions are ego-dystonic — the patient recognises them as irrational but cannot dismiss them. This is the defining feature that separates OCD from delusions (where insight is absent).
- ●Compulsions may be behavioural (tidying, checking, washing) or mental (counting, praying, repeating phrases). Both function as avoidance strategies that prevent the patient from learning that the feared outcome will not occur.
- ●In this case: the obsession is that imperfect symmetry will cause his mother's cancer to return; the compulsion is the nightly tidying ritual. The temporary anxiety relief the ritual provides is the engine keeping the cycle running.
Magical Thinking — OCD, Not Psychosis
- ●Magical thinking is the belief that one's actions or thoughts can influence unrelated external events (e.g. "if my room is not symmetrical, my mum's cancer will return"). It is a recognised and common feature of OCD — not a sign of psychosis or schizophrenia.
- ●The critical distinguishing feature is retained insight: the patient knows logically the belief is false but cannot resist acting on it. In psychosis, insight is absent — the patient believes the delusional thought to be literally true.
- ●GP trainees must address this distinction explicitly with the patient. Failing to do so leaves the patient's fear of "going crazy" or developing schizophrenia unresolved — the most significant source of shame and disengagement in this case.
- ●Screen actively for psychotic symptoms (hallucinations, thought disorder, formal delusions with absent insight) to exclude psychosis as a differential — Leo has none of these.
Severity Assessment and Functional Impairment
- ●Severity in OCD is determined primarily by functional impairment, not symptom count. Leo's presentation is moderate-to-severe: 3–4 hours of compulsions nightly, 4–5 hours sleep, failing academic performance, social withdrawal, and cessation of physical activity.
- ●Use a structured approach: assess impact across sleep, academic or occupational function, social relationships, and physical health.
- ●The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) or its adolescent equivalent (CY-BOCS) is the standard severity measure used in specialist services — familiarity with these tools helps GPs frame their referral appropriately.
- ●Identifying the psychological trigger (mother's cancer and treatment) is clinically important — stress-precipitated OCD is common, and understanding the onset context informs both psychoeducation and therapy planning.
First-Line Management — CBT with ERP
- ●NICE NG207 (OCD and BDD, 2022) recommends Cognitive Behavioural Therapy (CBT) incorporating Exposure and Response Prevention (ERP) as first-line treatment for OCD in children and young people.
- ●ERP works by deliberately exposing the patient to the anxiety-provoking trigger (e.g. leaving one item out of place) while preventing the compulsive response (not tidying it), and tolerating the resulting anxiety until it naturally subsides. Repeated exposures teach the brain that the feared outcome does not occur and that anxiety is tolerable without the compulsion.
- ●ERP must be structured, graduated, and professionally guided — it is not appropriate to instruct a patient to "just try leaving things messy" without therapeutic support. Unguided ERP in severe OCD is likely to trigger panic and erode engagement with treatment.
- ●A hierarchy of feared situations is constructed collaboratively with the therapist, starting with low-anxiety triggers and progressing gradually. The patient's sense of control over the pace is central to engagement.
Referral Pathway — CAMHS and CYP Services
- ●For moderate-to-severe OCD in under-18s, refer promptly to Child and Adolescent Mental Health Services (CAMHS) or the local young person's psychological therapy service (CYP IAPT pathway with OCD-specific expertise).
- ●Generic counselling or adult IAPT services are not appropriate for this presentation. ERP requires clinicians specifically trained in OCD treatment.
- ●Referral should be made at the first appointment given the degree of functional impairment — delays compound academic, social, and psychological harm in an adolescent with ongoing GCSE pressures.
- ●CAMHS waiting times can be substantial. Acknowledge this to the patient and provide interim support (see below).
Pharmacotherapy — Appropriate Positioning of SSRIs
- ●SSRIs are not first-line for OCD in under-18s as a standalone treatment. NICE NG207 recommends psychological therapy first.
- ●SSRIs are indicated as an adjunct to CBT, or as an alternative, if: the patient does not respond to or cannot engage with CBT; OCD is so severe that therapy engagement is not yet possible; or there is significant comorbid depression.
- ●Fluoxetine is the SSRI of choice in children and young people with OCD (licensed from age 8 for depression; used off-label for OCD in under-18s). Initiation in this age group is typically by a CAMHS specialist, not the GP.
- ●GPs should acknowledge the patient's preference regarding medication, avoid premature prescribing, and clearly position SSRIs as a valid option if therapy alone is insufficient — not a first resort.
Interim Support While Awaiting CAMHS
- ●Do not leave the patient unsupported during the referral gap. Provide specific signposting to:
- ●OCD-UK (ocduk.org) — patient-led charity with resources specifically designed for young people and families
- ●OCD Action (ocdaction.org.uk) — information, peer support, and guidance on navigating the treatment pathway
- ●Avoid advising family members to simply accommodate rituals during the waiting period — accommodation maintains and strengthens OCD. Brief psychoeducation for the family on this point is appropriate at the GP stage.
- ●Consider whether interim low-intensity support (e.g. guided self-help based on CBT principles) is appropriate for milder features, while awaiting specialist input for the core presentation.
Family Involvement in OCD Management
- ●Family accommodation — where family members modify their own behaviour to reduce the patient's OCD-driven distress (e.g. avoiding certain areas, providing reassurance, participating in rituals) — is associated with poorer treatment outcomes and maintains the disorder.
- ●Encouraging the patient to disclose their OCD to a trusted family member, and providing psychoeducation to that family member about accommodation, is an evidence-based component of OCD management in young people.
- ●In Leo's case, his mother's involvement is therapeutically important. Encouraging disclosure — and offering to facilitate or support that conversation — serves both his recovery and her ability to support him. Ensure this is done with the patient's agreement to preserve the therapeutic alliance.
- ●The father's non-involvement and the younger sister's home situation should also be noted as part of a holistic family picture.
School Communication and Functional Advocacy
- ●OCD causing significant academic impairment warrants a GP letter to the school explaining the medical context, requesting mitigating circumstances for affected mock exams and coursework, and flagging the potential need for pastoral or SEN support.
- ●This is an active management step, not an optional courtesy. Adolescents with untreated or undertreated OCD are at risk of significant academic under-achievement with long-term consequences — advocacy at the GP level can mitigate this.
- ●Consider whether an Education, Health and Care (EHC) needs assessment via the local authority may be appropriate if difficulties are likely to be sustained.
Safety Netting and Follow-up
- ●Arrange a specific follow-up appointment within 2–4 weeks to review Leo's wellbeing, confirm the referral has been processed, and assess for any deterioration in mood or risk.
- ●Give clear guidance on when to seek earlier review: significant worsening of mood or hopelessness, emergence of self-harm thoughts, inability to attend school, or escalating compulsions preventing basic daily function.
- ●Ensure Leo knows how to contact the practice before his follow-up if needed, and that he is aware of the Samaritans (116 123) or Childline (0800 1111) as external resources should he feel he cannot cope.
- ●A comprehensive risk screen is mandatory in this case: a sleep-deprived, socially isolated 16-year-old with a significant psychiatric presentation and a recently seriously ill parent. Leo denies self-harm ideation, but this must be actively established — not assumed.
Safeguarding Considerations
- ●Leo is a 16-year-old living with a mother who has recently completed cancer treatment, a 12-year-old younger sister, and a largely absent non-resident father. Consider whether either child may be in a position of vulnerability or informal caring responsibility.
- ●While this case does not present an immediate safeguarding concern, the household context warrants awareness — particularly regarding the younger sister, who may be less visible to services.
- ●Document safeguarding considerations explicitly in the clinical notes even when no action is immediately required.
Common Candidate Mistakes in This Case
- ●Missing the obsession: Accepting the compulsive behaviour (tidying) at face value without asking what Leo fears will happen if he stops — and therefore never uncovering the magical thinking or the link to his mother's cancer. The compulsion is always a response to an obsession; the obsession must be actively sought.
- ●Conflating magical thinking with psychosis: Assuming that an irrational belief (room cleanliness causing cancer) indicates psychosis, without checking for retained insight. This leads to an incorrect differential and fails to address Leo's central fear that he is "going crazy."
- ●Unguided ERP advice: Telling Leo to "just try leaving one thing out of place tonight" without explaining that ERP must be structured and professionally supervised. This is likely to cause acute distress and damage the therapeutic alliance.
- ●Referring to adult IAPT or generic counselling: Under-18s with moderate-to-severe OCD require CAMHS or a specialist CYP OCD service, not adult or non-specialist services.
- ●Prescribing SSRIs immediately: Offering medication as a first step to a 16-year-old who has expressed a clear preference for talking therapy, without positioning it correctly as a second-line or adjunct option per NICE NG207.
Mapped to the RCGP curriculum topic: Mental Health.
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