CASE INFORMATION

Case ID: CCE-2025-004
Case Name: James Carter
Age: 32
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: P72 (Affective Psychosis)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages empathetically 1.2 Uses appropriate questioning techniques to explore mood and psychotic symptoms 1.4 Communicates effectively in routine and challenging situations
2. Clinical Information Gathering and Interpretation	2.1 Conducts a structured psychiatric history 2.2 Assesses for red flags requiring urgent intervention
3. Diagnosis, Decision-Making, and Reasoning	3.1 Differentiates between affective psychosis, schizophrenia, and organic causes 3.3 Recognises the need for risk assessment and urgent psychiatric referral
4. Clinical Management and Therapeutic Reasoning	4.2 Develops a safe and patient-centred management plan 4.4 Balances medication initiation with psychosocial interventions
5. Preventive and Population Health	5.3 Provides education on medication adherence and relapse prevention
6. Professionalism	6.2 Ensures patient autonomy while managing risk appropriately
7. General Practice Systems and Regulatory Requirements	7.1 Completes appropriate mental health documentation and referrals
9. Managing Uncertainty	9.2 Identifies the need for urgent psychiatric intervention vs. outpatient management
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises acute psychiatric deterioration and ensures patient safety

CASE FEATURES

Young man presenting with recent-onset psychotic symptoms in the context of mood instability.
History of depressive and manic symptoms, suggestive of bipolar disorder with psychotic features.
Experiencing grandiose delusions and reduced need for sleep.
Family members are concerned about his erratic behaviour and poor insight.
Requires urgent psychiatric assessment and risk management.

INSTRUCTIONS

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

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

You are not required to perform a physical examination.

A patient record summary is provided for your information.

Perform the following tasks:

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

SCENARIO

James Carter, a 32-year-old marketing consultant, has been brought to the clinic by his sister, who is worried about his behaviour over the past two weeks.

She describes sudden changes in his mood, including elevated energy levels, decreased need for sleep, excessive spending, and grandiose beliefs. He has withdrawn from work, claiming he is destined to become a millionaire through an undisclosed business idea.

His BP today is 126/78 mmHg, HR 88 bpm, and he appears alert but restless.

PATIENT RECORD SUMMARY

Patient Details

Name: James Carter
Age: 32
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

None currently

Past History

History of one major depressive episode at age 27, treated with SSRIs for six months
No known history of bipolar disorder or schizophrenia

Family History

Mother had bipolar disorder, requiring hospitalisation in her 40s

Social History

Works as a marketing consultant but has stopped working recently.

Smoking & Alcohol

Occasional alcohol use.
No illicit drug use reported.

Vaccination & Preventative Activities

All vaccinations up to date.

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.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I don’t know why my sister brought me here. I feel fantastic! I’ve never thought more clearly in my life.”

General Information

You feel better than ever and don’t understand why your sister is worried.
You have barely slept in the past five days but don’t feel tired.
You have a revolutionary business idea that will make you millions.
You recently spent $10,000 on a business plan that you haven’t fully explained.

Specific Information

(Reveal Only When Asked)

Background Information

You feel incredibly confident, powerful, and insightful.
You talk fast, with racing thoughts, and struggle to stay on one topic.
You deny needing help, believing this is your true self, finally reaching your full potential.

Mood & Energy

You feel “unstoppable”, like you have finally unlocked your true potential.
You don’t feel the need to eat or rest, though you’ve been drinking more coffee.
You feel like you are making connections faster than ever before, but sometimes your thoughts move too quickly.
If asked about past depressive episodes, you dismiss them as “a phase I outgrew.”

Psychotic Features

You believe you have special abilities, particularly predicting financial trends.
You feel like everything is lining up perfectly for you, as if the universe is guiding you.
You deny hearing voices, but you believe you receive special messages through advertisements and numbers on licence plates.
If challenged, you may become defensive, saying, “You just don’t understand! Normal people don’t get this.”

Insight & Judgment

You insist that you do not need help.
You strongly resist the idea of medication, saying, “Why would I want to dull my brilliance?”
You dismiss concerns about money, saying, “Investments aren’t about money, they’re about vision!”
You don’t believe you need a psychiatrist but would consider a “business coach”.

Emotional Cues

Euphoria & Grandiosity

You smile constantly, exuding enthusiasm and energy.
You lean forward in your seat, making exaggerated hand gestures.
You may interrupt the doctor frequently because your mind is racing ahead.
You believe you are the smartest person in the room.

Irritability & Defensiveness

If the doctor challenges your beliefs, you become frustrated and dismissive.
You may say: “Why is everyone trying to slow me down? Do you want me to fail?”
If pressed about seeing a psychiatrist, you may respond: “I don’t need a shrink. I need someone who understands success!”

Mild Paranoia

If the doctor asks about hospital admission, you might say:
- “Are you trying to control me?”
- “My sister is overreacting. She just doesn’t want to see me succeed.”
If pressed further, you might say: “Are you working with her? Do you think I’m crazy?”

Key Questions for the Candidate

(Ask these naturally throughout the consultation, especially if the doctor hasn’t already addressed them.)

“Why does everyone keep saying I’m sick when I feel so good?”
“Do I really need medication? What if I just keep going like this?”
“Are you trying to control me? I should be free to do what I want!”
“If I take medication, will I lose my creativity?”
“I don’t have time for this! Can we wrap this up?”

Possible Patient Reactions Based on the Candidate’s Response

If the Doctor Engages Empathetically & Builds Rapport

You become slightly more cooperative but still resistant to treatment.
If the doctor frames the need for treatment in a way that preserves your autonomy, you may say:
- “Alright, I guess I could talk to someone… but only if they’re serious about success.”
- “Fine, I’ll try medication, but only the smallest dose.”

If the Doctor is Dismissive or Too Confrontational

You become angry and defensive, possibly standing up or trying to leave.
You might say:
- “I knew this was a waste of time. You’re just like everyone else!”
- “You don’t get it. I don’t need help—I need support!”

If the Doctor Focuses Too Much on the Sister’s Concerns Rather Than Yours

You feel ganged up on and say, “So you’re taking her side? I thought you were my doctor, not hers!”
You may refuse to cooperate entirely, saying: “This is pointless. I’m leaving.”

Role-Player’s Objective

Encourage the candidate to take a structured approach to history-taking:
- Differentiate between affective psychosis, schizophrenia, and organic causes.
- Identify risk factors (e.g., impulsive behaviour, financial loss, sleep deprivation).
Assess whether the candidate prioritises patient safety, particularly:
- Risk of financial harm or reckless behaviour.
- Risk of harm to self or others (driving recklessly, substance use, legal risks).
- Need for urgent psychiatric referral or possible hospital admission.
Observe if the candidate can de-escalate tension and build rapport without being confrontational.
Determine if the candidate can balance autonomy and safety, ensuring the patient feels heard while managing risks appropriately.

How to Adapt Depending on the Candidate’s Approach

If the Doctor is Calm, Empathetic, and Non-Judgmental

You open up more and consider treatment as an option.
You may agree to psychiatric referral if it’s framed as helping you “maximise your potential”.

If the Doctor Focuses Too Much on a Medicalised Explanation

You become frustrated and disengaged, feeling like the doctor “doesn’t get it”.
You may refuse psychiatric referral or reject medication outright.

If the Doctor Becomes Too Directive Too Quickly

You push back and become increasingly paranoid and defensive.
You might accuse the doctor of conspiring with your sister.
If the doctor mentions involuntary hospitalisation, you become visibly agitated and may threaten to leave immediately.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a structured psychiatric history, including mood symptoms and psychotic features.

The competent candidate should:

Establish rapport and create a safe, non-judgmental space, using calm, open-ended questions.
Conduct a structured psychiatric history, covering:
- Mood symptoms:
  - Elevated mood (grandiosity, increased confidence, reduced need for sleep).
  - Pressured speech, flight of ideas, racing thoughts.
  - Impulsivity (financial decisions, spending sprees).
- Psychotic symptoms:
  - Grandiose delusions (believing in special abilities or destined success).
  - Possible paranoid thoughts (suspicion of others controlling him).
  - Perceptual disturbances (hallucinations, unusual sensory experiences).
- Insight & judgement: Assess awareness of symptoms and ability to make decisions.
- Risk assessment: Evaluate:
  - Self-harm or suicidal ideation.
  - Harm to others (agitation, aggression).
  - Financial, occupational, and social risks.
Explore triggers (stress, sleep deprivation, substance use, recent medication changes).
Review past psychiatric history and family history of bipolar disorder or psychosis.

Task 2: Explain the likely diagnosis and the need for further assessment.

The competent candidate should:

Clearly explain the diagnosis in non-judgmental, patient-friendly language:
- Likely experiencing a manic episode with psychotic features, most consistent with bipolar affective disorder type I.
Differentiate affective psychosis from other conditions, including:
- Schizophrenia (less mood instability, more persistent psychotic symptoms).
- Substance-induced psychosis (ask about stimulant or cannabis use).
- Organic causes (thyroid dysfunction, neurological conditions).
Emphasise that a psychiatrist’s assessment is essential to confirm the diagnosis and guide treatment.
Reassure the patient that treatment can help stabilise mood, improve insight, and restore functioning.
Address the need for urgent assessment, due to financial risks, impaired judgment, and possible safety concerns.

Task 3: Outline your immediate management plan, including risk assessment and referral.

The competent candidate should:

Prioritise patient safety:
- Immediate psychiatric referral: Arrange urgent review by a psychiatrist for assessment and possible hospital admission.
- Risk management: Assess suicidal ideation, self-neglect, harm to others, and financial risks.
- Consider hospitalisation if:
  - The patient lacks insight and refuses treatment.
  - There is high risk of harm or severe functional impairment.
Medication initiation:
- If safe for outpatient management, consider starting an antipsychotic (e.g., olanzapine or quetiapine) and a mood stabiliser (e.g., lithium, valproate).
- Educate on side effects and importance of adherence.
Supportive measures:
- Involve family members to provide monitoring and support.
- Ensure regular follow-up within 24–48 hours.

Task 4: Address the patient’s concerns, including autonomy and the impact on his daily life.

The competent candidate should:

Acknowledge the patient’s perspective while balancing autonomy with safety.
Address concerns about medication:
- Reassure that treatment won’t change their personality but will restore clarity and balance.
- Explain that untreated mania can worsen and lead to severe consequences.
Discuss impact on work and finances:
- Encourage temporary leave from work to focus on recovery.
- Advise limiting financial decisions and consider family oversight.
Driving and legal responsibilities:
- Inform the patient that driving restrictions may apply due to impaired judgment.
Offer support resources, such as Beyond Blue, Black Dog Institute, and family support groups.

SUMMARY OF A COMPETENT ANSWER

Takes a comprehensive psychiatric history, covering mood, psychotic symptoms, and risk assessment.
Differentiates bipolar affective disorder from schizophrenia and organic causes.
Explains the need for urgent psychiatric assessment, balancing empathy with safety concerns.
Develops a clear management plan, including medication, family involvement, and follow-up.
Addresses the patient’s concerns about autonomy, treatment, and the impact on daily life.

PITFALLS

Failing to recognise the urgency – not arranging urgent psychiatric referral or considering hospitalisation.
Over-reassuring without discussing risks – minimising financial or occupational consequences.
Not addressing risk factors – failing to explore suicidal ideation, impulsivity, or harm to others.
Avoiding discussion of medication – not explaining treatment options clearly.
Neglecting family involvement – not engaging the sister or considering a support plan.

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 Areas Assessed

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Uses appropriate questioning techniques to explore mood and psychotic symptoms.
1.4 Communicates effectively in routine and challenging situations.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a structured psychiatric history.
2.2 Assesses for red flags requiring urgent intervention.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between affective psychosis, schizophrenia, and organic causes.
3.3 Recognises the need for risk assessment and urgent psychiatric referral.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a safe and patient-centred management plan.
4.4 Balances medication initiation with psychosocial interventions.

5. Preventive and Population Health

5.3 Provides education on medication adherence and relapse prevention.

6. Professionalism

6.2 Ensures patient autonomy while managing risk appropriately.

7. General Practice Systems and Regulatory Requirements

7.1 Completes appropriate mental health documentation and referrals.

9. Managing Uncertainty

9.2 Identifies the need for urgent psychiatric intervention vs. outpatient management.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises acute psychiatric deterioration and ensures patient safety.

Competency at Fellowship Level

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