CCE-CE-080

CASE INFORMATION

Case ID: CCE-PSY-001
Case Name: Michael Patterson
Age: 28
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: P72 – Schizophrenia

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages the patient
1.2 Explores the patient’s concerns, ideas, and expectations
1.3 Communicates effectively with the patient and caregiver (if present)
2. Clinical Information Gathering and Interpretation2.1 Takes a structured psychiatric history, including symptom onset, severity, and impact on daily life
2.2 Assesses for medication adherence, side effects, and substance use
3. Diagnosis, Decision-Making and Reasoning3.1 Recognises signs of relapse and assesses risk
3.2 Determines if hospitalisation or specialist input is required
4. Clinical Management and Therapeutic Reasoning4.1 Develops a structured management plan for schizophrenia, including medication adherence and psychoeducation
4.2 Identifies the need for psychosocial support and multidisciplinary involvement
5. Preventive and Population Health5.1 Assesses lifestyle factors and physical health monitoring for antipsychotic side effects
6. Professionalism6.1 Demonstrates empathy and a non-judgmental approach
7. General Practice Systems and Regulatory Requirements7.1 Documents consultation findings, risk assessment, and management plans appropriately
9. Managing Uncertainty9.1 Recognises early warning signs of deterioration and takes appropriate action
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies patients at risk of harm to self or others and implements appropriate interventions

CASE FEATURES

  • Opportunity to discuss long-term management, including psychosocial support.
  • Young male with schizophrenia presenting with worsening symptoms.
  • Recent non-adherence to medication.
  • Experiencing auditory hallucinations and paranoid delusions.
  • Concerns from family about social withdrawal and lack of self-care.
  • Possible substance use complicating management.
  • Risk assessment required for self-harm or harm to others.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

Michael Patterson is a 28-year-old unemployed man diagnosed with schizophrenia five years ago. His mother booked this appointment because she is worried about his behaviour and self-care.

His symptom history includes:

  • Stopped taking risperidone 2 months ago.
  • Increasing auditory hallucinations (voices commenting on his actions).
  • Paranoid thoughts that neighbours are spying on him.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Patterson
Age: 28
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known drug allergies

Medications

  • Previously on risperidone 4mg daily but stopped 2 months ago

Past History

  • Schizophrenia diagnosed at age 23.
  • Three previous psychiatric hospitalisations, last one 1.5 years ago.
  • No chronic physical illnesses.

Social History

  • Unemployed, lives with mother.
  • Occasional cannabis use.

Family History

  • Mother has depression, well managed with medication.
  • No family history of schizophrenia.

Preventive Activities

  • NIL

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I don’t think I need my medication anymore. It makes me feel weird.”

General Information

Michael Patterson is a 28-year-old man diagnosed with schizophrenia at age 23. He has had multiple hospitalisations in the past but has been stable for the past 18 months on risperidone 4mg daily. However, he stopped taking his medication two months ago without consulting his doctor. His mother booked this appointment because she is worried about his withdrawal and change in behaviour.

Michael does not think he is unwell and believes he is managing fine without medication, even though his paranoid thoughts and auditory hallucinations have worsened.

Current Presentation

  • Stopped taking medication 2 months ago due to side effects (sedation, weight gain).
  • Experiencing daily auditory hallucinations (voices commenting on his actions).
  • Believes his neighbours are spying on him and talking about him.

Specific Information

(To be revealed only when asked)

Background Information

  • Spending most of his time alone in his room, avoiding social contact.
  • Not showering or eating properly; mother brings food, but he often refuses it.
  • Occasional cannabis use “to relax”.
  • Mother reports that he is more withdrawn and disconnected.

Medication and Side Effects

(Michael will describe the following when asked about his medication.)

  • Stopped risperidone because he felt slow, sluggish, and unmotivated.
  • Gained weight while on it and felt self-conscious.
  • Believes the medication was “changing his brain” in a bad way.
  • Felt like he was being controlled when taking medication.
  • Thinks he is better off without it.

Psychotic Symptoms

(Michael will reveal these details only if directly asked.)

  • Hearing voices every day for the past month.
  • Voices talk about him but don’t directly command him to do anything.
  • Feels that people are watching him and talking about him.
  • Locks his doors and closes curtains because he thinks he’s being watched.
  • Suspicious of his mother, thinks she might be “working with someone” to control him.

Social Withdrawal and Self-Care

(Michael will acknowledge these issues if prompted.)

  • Stopped going out, except for essentials.
  • No longer plays video games with friends online.
  • Hasn’t spoken to his closest friends in over a month.
  • Spends most of his time in his room, avoiding interaction.
  • Not showering regularly, wearing the same clothes for days.
  • Eats irregularly, sometimes skips meals completely.

Substance Use

(Michael will reveal this information only if asked directly.)

  • Smokes cannabis occasionally to “calm his mind.”
  • Denies using other drugs or alcohol.

Emotional Cues

Michael is calm but detached.

  • He is not aggressive or agitated but may become defensive if pushed.
  • He avoids eye contact and speaks in a monotonous tone.
  • If asked about his delusions, he may become more withdrawn or vague.
  • If the candidate is empathetic and patient, he may engage more in discussion.
  • If pressured about medication, he may shut down and refuse to talk.

Questions for the Candidate

Michael may ask some or all of the following:

  1. “Why do I need medication if I feel fine?”
  2. “What happens if I don’t take it?”
  3. “Are you going to make me go to hospital?”
  4. “Is my mum overreacting?”
  5. “Can I just use cannabis instead of my meds?”
  6. “Are you part of this too? Are you working with my mum to make me take medicine?”

Expected Reactions Based on Candidate Performance

If the candidate provides empathetic, structured care:

  • Michael will be more open to discussion about medication.
  • He may agree to resume medication if offered a different option with fewer side effects.
  • He may accept a referral to a psychiatrist or community mental health team.

If the candidate is dismissive or too forceful:

  • Michael will become defensive and resistant to treatment.
  • He may refuse to engage further and decline follow-up.
  • He may express suspicion that the doctor is trying to control him.

Key Takeaways for the Candidate

  • Elicit Michael’s perspective and concerns about medication without immediately challenging his beliefs.
  • Assess risk carefully, including potential for self-harm, harm to others, or neglect.
  • Recognise early warning signs of psychotic relapse, including paranoia, hallucinations, and social withdrawal.
  • Provide a non-confrontational discussion about medication adherence and explore alternative options.
  • Consider involving the mother as a collateral historian, while respecting Michael’s autonomy.
  • Arrange urgent psychiatric review if required, particularly if there is significant risk of deterioration.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including recent symptoms, medication adherence, substance use, and functional impact.

The competent candidate should:

  • Elicit details of symptom progression, including:
    • Auditory hallucinations (frequency, content, distress level).
    • Paranoid delusions (degree of conviction, impact on daily life).
    • Level of insight and perceived need for treatment.
  • Assess medication adherence:
    • Reason for stopping risperidone (side effects, beliefs about medication).
    • Previous treatment experiences and alternative options.
  • Evaluate impact on daily functioning:
    • Social withdrawal, self-care, and relationships.
    • Employment and routine activities.
  • Screen for substance use:
    • Cannabis use (frequency, dependency, worsening of symptoms).
    • Alcohol or other drug use.

Task 2: Conduct a risk assessment for self-harm, harm to others, or need for hospitalisation.

The competent candidate should:

  • Assess risk of self-harm or suicide:
    • Any thoughts of harm to self?
    • Previous attempts or self-injurious behaviour.
  • Assess risk to others:
    • Paranoia affecting interactions (any aggressive thoughts or behaviour).
    • Concerns from family or past history of violence.
  • Determine need for hospitalisation:
    • Severe functional decline or inability to care for self.
    • Acute psychotic symptoms with high distress or risk.
  • Consider involuntary treatment if:
    • Michael lacks insight and refuses care.
    • He is at imminent risk to himself or others.

Task 3: Provide a structured management plan, including medication adherence, psychosocial support, and follow-up.

The competent candidate should:

  • Discuss medication options:
    • Reintroduce risperidone with side effect management OR consider alternative antipsychotics (e.g., aripiprazole for lower sedation).
    • Consider long-acting injectables if adherence is an issue.
  • Engage Michael in shared decision-making:
    • “I understand you had concerns about your medication. Let’s explore ways to manage side effects while keeping your symptoms controlled.”
  • Offer psychosocial support:
    • Referral to community mental health services.
    • Psychoeducation for Michael and his mother on recognising early warning signs.
    • Encourage structured routine and social re-engagement.
  • Plan follow-up:
    • Review in 1 week to monitor symptoms and medication response.
    • Ensure crisis plan is in place if symptoms worsen.

Task 4: Communicate appropriately with the patient and, if appropriate, their caregiver.

The competent candidate should:

  • Use empathetic, non-judgmental communication:
    • “I hear that you’re feeling fine, but I can see your mother is quite concerned. Let’s work together to ensure you stay well.”
  • Acknowledge concerns about medication:
    • Address side effects and offer alternatives.
    • Reframe medication as a tool to maintain independence.
  • Ensure caregiver involvement while respecting autonomy:
    • Involve mother in safety planning.
    • Discuss carer support services if needed.

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured history, addressing psychotic symptoms, medication adherence, and functional impact.
  • Performs a thorough risk assessment, including suicidality, harm to others, and need for hospitalisation.
  • Engages in shared decision-making, balancing medication adherence with patient concerns.
  • Provides a structured management plan, including medication review, community support, and psychoeducation.
  • Uses empathetic communication, acknowledging patient autonomy while involving caregivers appropriately.

PITFALLS

  • Failing to assess medication adherence and reasons for stopping treatment.
  • Neglecting a thorough risk assessment, missing potential for self-harm, harm to others, or deterioration.
  • Overlooking the impact of substance use on psychotic symptoms.
  • Being too forceful about medication, leading to disengagement.
  • Not involving support systems, such as caregivers or mental health services.

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

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.3 Provides clear and structured explanations about schizophrenia, medication, and support options.

2. Clinical Information Gathering and Interpretation

2.1 Takes a detailed psychiatric history, including symptom onset and severity.
2.2 Assesses functional impact, medication adherence, and substance use.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises signs of schizophrenia relapse and the need for intervention.
3.2 Determines if hospitalisation or specialist input is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a structured management plan for schizophrenia, including medication adherence strategies.
4.2 Identifies need for psychosocial support and multidisciplinary care.

5. Preventive and Population Health

5.1 Assesses lifestyle factors and physical health monitoring for antipsychotic side effects.

6. Professionalism

6.1 Demonstrates empathy and a non-judgmental approach.

7. General Practice Systems and Regulatory Requirements

7.1 Documents consultation findings, risk assessment, and management plans appropriately.

9. Managing Uncertainty

9.1 Recognises early warning signs of deterioration and takes appropriate action.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies patients at risk of harm to self or others and implements appropriate interventions.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD