CASE INFORMATION
Case ID: BD-001
Case Name: Daniel Roberts
Age: 28 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: P73 (Bipolar Disorder)
COMPETENCY OUTCOMES
| Competency Domain | Competency Element |
|---|---|
| 1. Communication and Consultation Skills | 1.1 Establishes a safe and non-judgmental environment for discussing mental health 1.2 Uses empathetic listening and clear explanations about the condition and management 1.3 Engages the patient collaboratively in treatment planning |
| 2. Clinical Information Gathering and Interpretation | 2.1 Takes a thorough psychiatric history, including mood episodes, triggers, and functional impact 2.2 Conducts a risk assessment (suicide/self-harm, aggression, substance use) 2.3 Differentiates bipolar disorder from other mood disorders (e.g., unipolar depression, schizoaffective disorder) |
| 3. Diagnosis, Decision-Making and Reasoning | 3.1 Applies DSM-5 criteria for diagnosing bipolar disorder 3.2 Identifies early warning signs of manic and depressive episodes 3.3 Assesses for comorbidities such as anxiety, substance use, and metabolic risks |
| 4. Clinical Management and Therapeutic Reasoning | 4.1 Develops a long-term, evidence-based management plan 4.2 Discusses pharmacological options, including mood stabilisers and antipsychotics 4.3 Explores non-pharmacological approaches, such as psychoeducation and lifestyle strategies |
| 5. Preventive and Population Health | 5.1 Discusses early intervention strategies to prevent relapse 5.2 Educates on sleep hygiene, stress management, and substance avoidance |
| 6. Professionalism | 6.1 Demonstrates a compassionate, patient-centred approach, reducing stigma around mental illness |
| 7. General Practice Systems and Regulatory Requirements | 7.1 Ensures appropriate referrals (psychiatry, psychology) 7.2 Documents mental health care plans (MHCPs) and crisis plans accurately |
| 9. Managing Uncertainty | 9.1 Recognises when urgent psychiatric assessment is required (e.g., psychosis, suicidality) |
| 10. Identifying and Managing the Patient with Significant Illness | 10.1 Identifies high-risk features, including manic psychosis or suicidal ideation |
CASE FEATURES
- Young male presenting with fluctuating mood, sleep disturbance, and impulsive behaviours.
- Potential history of manic episodes, requiring assessment using DSM-5 criteria.
- Consideration of safety risks, including suicidal ideation and risky behaviour.
- Discussion about long-term mood stabilisation, lifestyle management, and referral pathways.
CANDIDATE INFORMATION
INSTRUCTIONS
Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.
You have 15 minutes to complete this case.
The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:
- Question 1 – 3 minutes
- Question 2 – 3 minutes
- Question 3 – 3 minutes
- Question 4 – 3 minutes
- Question 5 – 3 minutes
PATIENT RECORD SUMMARY
Patient Details
Name: Daniel Roberts
Age: 28 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- No known allergies
Medications
- None currently prescribed
Past History
- Diagnosed with major depressive disorder (MDD) at age 22, treated with SSRIs intermittently.
- Episodes of elevated mood in the past, but never formally diagnosed with bipolar disorder.
- One past hospitalisation for severe depression with suicidal ideation (age 25).
- No history of psychotic symptoms.
Social History
- Works as a graphic designer, recently started his own business.
- Reports increased financial strain.
- In a long-term relationship, partner concerned about recent erratic behaviour.
- Alcohol use: 10-12 drinks per week.
- Occasional cannabis use.
Family History
- Father diagnosed with bipolar disorder.
- No known history of schizophrenia or other psychiatric illnesses.
Vaccination and Preventative Activities
- Up to date with general health checks, no recent cardiovascular screening.
SCENARIO
Daniel, a 28-year-old male, presents to his GP at the insistence of his partner, who is concerned about his erratic behaviour and lack of sleep over the past two weeks. He describes feeling “on top of the world”, needing only 3 hours of sleep per night, and having boundless energy. He has invested a large sum of money impulsively into a new business idea and has engaged in risky behaviours, including excessive alcohol consumption and impulsive spending.
He admits to previous depressive episodes, during which he felt low energy, worthless, and struggled to get out of bed. He has had suicidal thoughts in the past but denies current intent or plan.
Your role is to assess Daniel’s mood symptoms, differentiate between bipolar disorder and other conditions, assess safety risks, and develop an appropriate management plan.
EXAMINATION FINDINGS
General Appearance: Well-groomed but highly animated, speaks quickly, pressured speech
Mood and Affect: Elevated, euphoric mood, with occasional irritability
Thought Process: Flight of ideas, tangential speech
Perception: No hallucinations
Cognition: Alert, poor insight into behaviour
Risk Assessment: No current suicidal intent but history of past suicidal ideation; high-risk impulsivity noted
Physical Examination: Normal vital signs, no signs of substance withdrawal
EXAMINER ONLY INFORMATION
QUESTIONS
Q1. How would you assess Daniel’s mood symptoms to determine if he has bipolar disorder?
- Prompt: What key aspects of history would you explore?
- Prompt: What diagnostic criteria apply for bipolar disorder?
Q2. What immediate management steps would you take?
- Prompt: How would you manage safety concerns?
- Prompt: When would hospitalisation be indicated?
Q3. What pharmacological and non-pharmacological treatment options would you discuss?
- Prompt: What are the first-line medications for bipolar disorder?
- Prompt: What lifestyle and psychological strategies are beneficial?
Q4. How would you counsel Daniel on the importance of mood stabilisation and adherence to treatment?
- Prompt: How do you explain the risks of untreated bipolar disorder?
- Prompt: How do you encourage adherence to medication and lifestyle changes?
Q5. What long-term preventive strategies should be discussed to reduce relapse risk?
- Prompt: What are the triggers for relapse?
- Prompt: What ongoing monitoring and support systems should be in place?
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Q1: How would you assess Daniel’s mood symptoms to determine if he has bipolar disorder?
A structured assessment involves history-taking, application of DSM-5 criteria, and ruling out differentials.
1. History-Taking
- Mood changes: Euphoria, irritability, impulsivity.
- Sleep patterns: Decreased need for sleep without fatigue.
- Energy and activity levels: Increased goal-directed activity.
- Cognitive and behavioural changes: Risk-taking, spending sprees.
- Psychotic features: Hallucinations, delusions.
- Past depressive episodes: Duration, severity, suicidal ideation.
- Substance use: Alcohol, cannabis contributing to mood instability.
2. Application of DSM-5 Criteria for Bipolar Disorder
- Bipolar I: At least one manic episode (≥1 week, severe impairment).
- Bipolar II: At least one hypomanic episode (≥4 days, no significant impairment) and a major depressive episode.
- Current Presentation: Daniel’s elevated mood, reduced sleep, pressured speech, flight of ideas, and impulsivity suggest mania.
3. Differentials to Consider
- Unipolar depression with hypomanic symptoms.
- Substance-induced mood disorder.
- Schizoaffective disorder (if psychosis was present).
Conclusion: Daniel’s symptoms are highly suggestive of Bipolar I disorder.
Q2: What immediate management steps would you take?
1. Risk Assessment
- Suicidal/self-harm risk: No current intent but past history.
- Aggression/impulsivity: Risk of financial loss, legal issues.
- Substance use: Aggravating mood instability.
2. Immediate Interventions
- Medication initiation:
- Mood stabiliser (e.g., lithium, valproate) or atypical antipsychotic (e.g., quetiapine).
- Psychosocial support:
- Family involvement in monitoring behaviour.
- Psychoeducation on illness awareness.
3. Indications for Urgent Psychiatric Referral
- Severe mania: Significant impairment, high-risk behaviours.
- Suicidality or aggression: Risk to self or others.
- Lack of insight: Non-adherence risk.
Conclusion: Daniel requires urgent psychiatric review and likely admission.
Q3: What pharmacological and non-pharmacological treatment options would you discuss?
1. Pharmacological Management
- Mood stabilisers:
- Lithium (first-line, requires blood monitoring).
- Valproate (effective but contraindicated in pregnancy).
- Atypical antipsychotics:
- Quetiapine, olanzapine (for acute mania, also used long-term).
- Benzodiazepines (short-term) for agitation.
2. Non-Pharmacological Approaches
- Psychoeducation: Understanding early warning signs.
- Psychological therapy: CBT, interpersonal therapy.
- Lifestyle modifications: Regular sleep, exercise, substance avoidance.
- Family involvement: Support networks.
Conclusion: A combination of medication and psychological support is key.
Q4: How would you counsel Daniel on the importance of mood stabilisation and adherence to treatment?
1. Educating on Bipolar Disorder
- Chronic condition requiring lifelong management.
- Consequences of untreated illness: Financial, legal, interpersonal risks.
2. Medication Adherence
- Mood stabilisers reduce relapse risk.
- Regular blood tests for lithium and valproate.
3. Identifying Early Warning Signs
- Manic triggers: Sleep deprivation, stress.
- Depressive symptoms: Social withdrawal, low energy.
4. Encouraging a Collaborative Approach
- Shared decision-making in treatment.
- Referral to a psychiatrist for long-term management.
Conclusion: Adherence to medication and lifestyle changes significantly improves outcomes.
Q5: What long-term preventive strategies should be discussed to reduce relapse risk?
1. Identifying Triggers
- Sleep deprivation, stress, substance use.
- Early intervention for mood changes.
2. Regular Monitoring
- Routine psychiatric follow-ups.
- Family/carer involvement in monitoring behaviour.
3. Lifestyle Modifications
- Regular sleep and structured routine.
- Avoidance of drugs and alcohol.
4. Crisis Management Plan
- Emergency contacts if symptoms escalate.
- Mental health care plan for ongoing support.
Conclusion: A preventive approach reduces hospitalisations and improves quality of life.
SUMMARY OF A COMPETENT ANSWER
- Thorough history and application of DSM-5 criteria for bipolar disorder.
- Risk assessment and immediate management of mania.
- Multimodal treatment approach (medication, psychology, lifestyle).
- Emphasis on medication adherence and psychoeducation.
- Preventive strategies to minimise relapse risk.
PITFALLS
- Failing to conduct a comprehensive risk assessment.
- Misdiagnosing bipolar disorder as unipolar depression.
- Not considering substance-induced mood disorder as a differential.
- Delaying psychiatric referral when urgent intervention is needed.
- Lack of long-term management planning, including lifestyle modifications.
REFERENCES
MARKING
Each competency area is on the following scale from 0 to 3.
☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD