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The Complete Doctor Academy · CASC Three-Track · General Adult (Chapter 4)

Temporal Lobe Epilepsy — a brain story wearing a psychiatric mask

Maudsley CASC · Station 4.34 · 90-second read · history + explanation · 'sees herself from above', 'nothing is real' — and odd facial movements
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station time
Dr Chinonso S. Ezeanyika · Where Simplicity Meets Excellence
Candidate Script
Actor Script
Examiner Marksheet 🔒
Candidate Instructions — verbatim
Maudsley source · the only thing you see at the door

Candidate Instructions. You are working for a neuropsychiatry outpatient team and have received a GP referral for Ms Yewande French, a 22-year-old woman who has been having brief, unusual experiences for the past two years. She feels as if she can see herself from above and has a strong sense that nothing around her is real. These periods usually last a few minutes and are accompanied by some odd facial movements. Take a focused history from this patient and explain what you think the diagnosis might be.

Given at the door — you may know this Your task
The referral hands you depersonalisation, derealisation and automatisms. The mask is psychiatric (dissociation, anxiety, psychosis); the answer is neurological. The verb is focused history → explain the likely diagnosis — so be precise about the seizure semiology.
Actor Instructions — the patient's brief
A study document — surfaces only as she reveals it, in the room
⚠ You would never see this in the exam. Vagueness is the trap — she's vague unless asked specifically. The diagnostic gold is the OLFACTORY aura (onions), the lip-smacking AUTOMATISMS, post-ictal confusion, and FEBRILE CONVULSIONS as a baby. Miss the specificity and you miss temporal lobe epilepsy.

Actor Instructions. You are 22-year-old Ms Yewande French, worried about seeing a psychiatrist — you don't think you have a psychiatric issue, but friends and family fear something's wrong with your brain. You're initially anxious; if the doctor is calm and reassuring you relax and talk openly. You are vague unless asked specifically about symptoms. Experiences began at age 20, about once a month. During them you get an odd sense that nothing is real, sometimes with a strange smell of onions cooking. After this you feel as if you're viewing yourself from above. It lasts a few minutes and you're conscious throughout. Friends/family say that during these you say 'it's happening again' and mention the onion smell; afterward you sit very still for a few minutes and occasionally make smacking movements with your lips and open your eyes wide. Later you feel tired and confused about what happened. Episodes get more frequent when you're tired or after drinking alcohol — so you've stopped alcohol and look after yourself (diet, exercise, sleep). You find them disconcerting and frightening; you've searched online and want reassurance it isn't a brain tumour or that you're going mad. You're keen to know the diagnosis. You've cut your graphic-design job to part time (worried about an episode at work) and socialise less; this has affected your mood over the past six months, but you'd feel better with an answer. If asked specifically: you had a couple of fits as a baby, both times unwell with a temperature (febrile). No serious head injury, no brain infections. No family history of epilepsy.

Key levers — the specific semiology she'll only give if asked precisely
Examiner — Feedback Domains
Tick-boxes glow as you earn them
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The examiner marksheet unlocks when you've answered every turn in this station.

Turn 1 / 8 0:00 WARM-UP
Ms French is anxious and reluctant — she doesn't think she has a psychiatric problem, but her family fear something's wrong with her brain. The referral mentions feeling unreal, seeing herself from above, and odd facial movements. How do you open?
Choose the best option — the clinical reasoning is revealed only after you commit.
A
She feels detached from reality — explore this as possible dissociation.
“Hello. These feelings of being detached and unreal — let's explore your emotions and any stress behind them.”
Frames it as dissociation/anxiety → the psychiatric mask.
B
She's anxious and fears she's 'going mad'. Settle her with a calm, reassuring frame, then invite a precise account of the episodes.
“Hello Ms French, I'm Dr [name]. I know coming here felt worrying, but you're in the right place and nothing you say will sound mad to me. These episodes sound very specific — could you talk me through exactly what one is like, from the very beginning?”
Calms her + invites precise account → she relaxes and details emerge.
C
The facial movements suggest a tic disorder — ask about those.
“Hello. Tell me about these facial movements — are they tics you can suppress?”
Anchors on one sign → misses the whole episode structure.
D
Screen mood first since she may be depressed.
“Hello. Have you been feeling low or depressed lately?”
Mood-first → chases the secondary symptom.
Quiz complete — your score for this station
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Turn Navigator

Answered 0 / 8 · Correct 0
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Pick the best opening or next move. The reasoning behind each option is hidden until you answer — so the right one isn't given away. Teaching unlocks when every turn is answered.
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Transferable Skills & the Station Pathway are locked

Finish the quiz for this station to reveal the defended transferable skills and the at-a-glance pathway. No peeking — that's the point.

Carry these out of the station

Transferable Skills — Defended

Tap each question to reveal the clinical defence and the patient-facing way to say it — never the textbook line.

1Depersonalisation and derealisation sound psychiatric — why isn't this dissociation or anxiety?›
Because they come as stereotyped, time-limited episodes with an olfactory aura (onions), automatisms (lip-smacking, eyes wide) and post-ictal confusion, worsened by tiredness and alcohol. Dissociation and anxiety don't produce that semiology. The psychiatric symptoms are the seizure's content, not the diagnosis.
These experiences sound very specific and brief, and they seem to follow a set pattern — can you walk me through exactly what one is like, from the very start?
2Why does being SPECIFIC decide this station?›
She is vague unless asked specifically. A loose history yields 'feeling unreal' and nothing diagnostic; precise questions surface the aura, automatisms and post-ictal state that make temporal lobe epilepsy. The author's note is explicit: a vague history won't be diagnostically helpful.
I'm going to ask some quite precise questions — what happens just before, what happens during, and how you feel afterwards. The detail really matters.
3What must I specifically ask about the aura?›
Unusual smells and epigastric fullness are the classic temporal-lobe auras and are easily missed. Here she gets a smell of onions cooking and a sense nothing is real. You usually have to ask directly.
Just before an episode, do you ever notice a strange smell or taste, or an odd feeling rising from your stomach?
4Why is collateral about the automatisms so valuable?›
She's conscious but won't fully see her own automatisms. Friends/family report she says 'it's happening again', then sits still, smacks her lips and opens her eyes wide, and is afterwards tired and confused — the during-and-after that clinches the seizure.
Have your friends or family described what you look like during one of these? What do they say you do, and how are you straight afterwards?
5How do precipitants help me?›
The episodes worsen with tiredness and alcohol — classic seizure precipitants — which is why she's already stopped drinking. Precipitants point toward a seizure disorder and away from a primary psychiatric cause.
Have you noticed anything that makes them more likely — being tired, drinking alcohol, missing sleep, stress?
6What neurological substrate must I ask about?›
Febrile convulsions as a baby (present here — fits while feverish), head injury, brain infections (encephalitis/meningitis), and family history of epilepsy. The childhood febrile convulsions are the gold thread to temporal lobe epilepsy.
Can I ask about your early life — were you ever told you had fits as a baby, perhaps with a high temperature? Any serious head injuries or brain infections? Any epilepsy in the family?
7How do I handle the low mood without being derailed?›
Her mood has dipped over six months — but it's secondary to the frightening episodes and the way they've shrunk her life (part-time work, less socialising). Acknowledge it genuinely, then return to the neurological thread; an answer about the episodes is what will help her mood.
It makes complete sense that all this has worn you down and you've pulled back from work and friends — and getting to the bottom of the episodes is the thing most likely to help.
8How do I explain the likely diagnosis and answer her fears?›
Plain words: this looks like temporal lobe epilepsy — brief episodes caused by a burst of abnormal electrical activity in part of the brain. Directly address her fears: it isn't 'going mad', and on this picture it isn't a tumour; it's recognised and treatable. Confirm with bloods, EEG and an MRI.
From what you've described, this looks like a form of epilepsy that affects one part of the brain — it's not you going mad, and it's something we can investigate properly with a brain-wave test and a scan, then treat.
9The transferable move that wins disguised-neurological stations›
Calm the patient; be relentlessly specific about episode structure; hunt the aura and automatisms explicitly; pin down precipitants and the neurological substrate; treat psychiatric symptoms as possible seizure content; name the likely diagnosis plainly and set out the confirmatory tests. When 'psychiatric' symptoms are stereotyped, brief and patterned, think brain.
Everything you've told me fits a specific, recognisable pattern — and the next step is simple tests to confirm it, so we can treat it and get your life back.
Two nights before the exam · the whole station, cold

At a Glance — The Station Pathway

The task is the white beam; it refracts into the spectrum of beats. Read the big verbs for the route; read underneath for the detail.

The station in one breath
Ms French, 22, is referred to neuropsychiatry with two years of brief episodes: a sense that nothing is real, seeing herself from above, and odd facial movements. The psychiatric mask is obvious — depersonalisation, derealisation, even a hint of low mood — and a careless candidate reaches for dissociation or anxiety. But the detail betrays a brain story: stereotyped episodes with an olfactory aura (onions), lip-smacking automatisms, post-ictal confusion, worsened by tiredness and alcohol, in someone who had febrile convulsions as a baby. This is temporal lobe epilepsy. She's vague unless asked specifically — so the whole station turns on the precision of your seizure history, then a clear explanation and a plan of EEG and MRI.
refracts into the flow
teal beats = the semiology spine (be specific → aura → automatisms → precipitants → substrate → name it)
1
CALM HER FIRST
She's anxious and fears she's 'going mad' or has a tumour. A calm, reassuring manner is what lets her talk openly. "You're in the right place — let's work out together what's been happening."
2
BE SPECIFIC OR MISS IT
She is vague unless asked specifically. Pin down onset (age 20), frequency (monthly), and the structure: before, during, after each episode.
3
HUNT THE AURA
Ask explicitly about unusual smells and epigastric fullness — the classic temporal-lobe aura. Here: a smell of onions cooking and a sense nothing is real.
4
GET THE AUTOMATISMS
From collateral: she says 'it's happening again', then sits still, lip-smacking, eyes wide — automatisms — followed by tiredness and confusion. Post-ictal state seals it.
5
FIND PRECIPITANTS
Episodes worsen with tiredness and alcohol — she's already stopped drinking. Precipitants support a seizure disorder over a psychiatric one.
6
THE NEURO SUBSTRATE
Ask the neurology questions: febrile convulsions as a baby (present), head injury, brain infections, family history of epilepsy. The childhood febrile fits are the gold thread.
7
IMPACT & MOOD
She's cut to part-time work and socialises less; mood has dipped over six months — secondary to the episodes. Acknowledge it without losing the neurological thread.
8
NAME IT PLAINLY
Explain temporal lobe epilepsy in plain words, directly answering her fears: not madness, not (on this picture) a tumour — a treatable electrical disturbance in part of the brain.
9
THE PLAN
Confirm with bloods, EEG, and an MRI of the head. (Not a management station — but mentioning the path to a diagnosis reassures her.)
The spineThe referral is dressed as psychiatry — depersonalisation, derealisation, a touch of low mood — but the detail is neurological. Calm her enough to talk, then be relentlessly specific: stereotyped monthly episodes she's conscious through, an olfactory aura of onions, lip-smacking automatisms and post-ictal confusion seen by others, worsened by tiredness and alcohol, in someone who had febrile convulsions as a baby. That semiology is temporal lobe epilepsy. Acknowledge the secondary low mood and functional impact, then explain the diagnosis plainly — answering her fears of madness and tumour — and set out bloods, EEG and MRI. Stay vague, reach for dissociation, and the brain story slips past you.