CCE-CE-179

CASE INFORMATION

Case ID: PTSD-2024-001
Case Name: James Robertson
Age: 38
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: P15 – Post-Traumatic Stress Disorder


COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 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 of healthcare.
1.4 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation2.1 Gathers relevant clinical, psychological, and social information.
2.2 Identifies important patterns and red flags.
3. Diagnosis, Decision-Making, and Reasoning3.1 Forms a rational differential diagnosis.
3.2 Recognises when more information is needed to establish a diagnosis.
4. Clinical Management and Therapeutic Reasoning4.2 Develops and explains an appropriate management plan, including psychological and pharmacological options.
4.3 Engages the patient in shared decision-making.
5. Preventive and Population Health5.1 Identifies risks related to mental health deterioration and suicide prevention.
6. Professionalism6.1 Demonstrates a respectful and empathetic approach to trauma-informed care.
7. General Practice Systems and Regulatory Requirements7.1 Recognises when to refer for specialist psychiatric or psychological support.
9. Managing Uncertainty9.1 Supports a patient experiencing uncertainty about their symptoms and prognosis.
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises PTSD as a significant mental health condition requiring a multidisciplinary approach.

CASE FEATURES

  • Potential risk of suicidal ideation.
  • Male (38 years old), ex-military veteran, presenting with PTSD symptoms.
  • Experiencing flashbacks, hypervigilance, and difficulty sleeping.
  • Avoiding social situations and struggling with work performance.
  • Partner worried about mood swings and emotional detachment.
  • Not currently on treatment or engaged in therapy.
  • Concerns about stigma and fear of medication dependence.

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 an examination.

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

James Robertson, a 38-year-old ex-military veteran, presents to the clinic with his partner, who is concerned about his mood swings, withdrawal, and poor sleep. James reports experiencing intrusive thoughts, nightmares, and emotional numbness, which started after he was deployed overseas five years ago. He describes hypervigilance, irritability, and difficulty concentrating at work, leading to relationship tension and work-related stress.

James has not sought professional help previously due to concerns about stigma, career impact, and medication side effects. He uses alcohol to manage stress, occasionally binge drinking on weekends. His partner reports that he avoids crowds and has become easily startled.


PATIENT RECORD SUMMARY

Patient Details

Name: James Robertson
Age: 38
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Nil current medications

Past History

  • Served in the Australian Defence Force (ADF) – Deployed overseas
  • No previous psychiatric history documented

Social History

  • Lives with his partner

Family History

  • No known psychiatric conditions in the family

Smoking

  • Nil

Alcohol

  • Binge drinking on weekends (6+ drinks per session)

Vaccination and Preventative Activities

  • Up to date with vaccinations

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

“I don’t know if I should be here, but my partner insisted. I feel like I should be able to handle this on my own.”


General Information

This information can be freely shared if the candidate asks general open-ended questions like “Can you tell me more about what’s been happening?”

  • Personal Background: My name is James Robertson, I’m 38 years old. I live with my partner, Sarah, and work in security. I used to love hiking and playing footy with my mates, but now I mostly stay home.
  • Service History: I served in the Australian Defence Force and was deployed five years ago.
  • Symptoms: Since returning, I’ve been struggling with flashbacks, nightmares, and mood swings. I feel on edge all the time and get startled easily by loud noises.

Specific Information

Only share these details if the candidate asks relevant, targeted questions.

Background Information

  • Avoidance Behaviour: I avoid crowded places and don’t like to talk about what happened overseas. Even watching war-related TV shows makes me uncomfortable.
  • Sleep Issues: I have trouble sleeping—I wake up sweating, my heart racing, sometimes even yelling. My partner says I thrash around in my sleep.
  • Work Issues: I’m struggling to concentrate at work. I feel like I’m not doing my job properly, and I’m worried that I might lose my job if this continues.
  • Emotional State: I feel numb most of the time, like I’m just going through the motions. It’s hard to enjoy things I used to love.

Triggers

  • Loud noises, especially helicopters and sirens.
  • Crowded places – shopping centres, public transport.
  • News about conflicts or war-related movies.

Alcohol Use

  • I binge drink on weekends—it helps me “switch off.”
  • I don’t drink every day, but when I do, I sometimes have 6+ drinks in one sitting.

Relationship and Social Impact

  • My partner is worried about me, but I push her away.
  • I don’t see my mates much anymore—I just don’t feel like talking.
  • I feel like I can’t relate to people who haven’t been through what I have.

Concerns About Treatment

  • “I don’t want to be seen as weak.”
  • “I should be able to deal with this on my own.”
  • “I don’t want to be on medication for the rest of my life.”
  • “What if my employer finds out? Can I lose my job?”
  • “Talking about it just makes it worse – I’d rather forget.”

Suicidal Thoughts or Self-Harm

  • I haven’t self-harmed and haven’t attempted suicide.
  • Sometimes, I wonder if things will ever get better.
  • I feel hopeless some days, but I wouldn’t act on it.

Emotional and Behavioural Cues

  • You appear hesitant and withdrawn at the start, arms crossed or looking down.
  • If the candidate builds trust, you gradually open up, but still struggle to express emotions.
  • If pushed too hard, you become defensive, saying, “I don’t want to talk about that.”
  • If the candidate reassures you, you soften slightly and acknowledge, “Maybe I do need help.”

Questions You Might Ask

  • “Is this PTSD? How do you even diagnose it?”
  • “Are you going to put me on medication? I don’t want to rely on it.”
  • “What if my employer finds out? Can I lose my job over this?”
  • “I don’t want to talk to a psychologist – can’t I just get on with it?”
  • “Does this mean I’ll always feel this way?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient to explore their symptoms, concerns, and psychosocial impact.

The competent candidate should:

  • Establish rapport and provide a safe and non-judgmental space for the patient to share their concerns.
  • Ask open-ended questions to explore symptoms of PTSD, including flashbacks, nightmares, hypervigilance, avoidance behaviours, and emotional numbness.
  • Inquire about triggers, such as loud noises, crowded places, or media exposure.
  • Assess the impact on daily life, including work, relationships, and sleep.
  • Explore coping mechanisms, including alcohol use and social withdrawal.
  • Screen for coexisting mental health conditions, such as depression or anxiety.
  • Assess for suicidal ideation or self-harm risk, ensuring immediate safety planning if needed.

Task 2: Explain your working diagnosis and discuss PTSD with the patient.

The competent candidate should:

  • Clearly and empathetically explain PTSD as a recognised mental health condition, not a sign of weakness.
  • Describe how PTSD develops after exposure to trauma and its common symptoms.
  • Address stigma concerns and normalise the condition, using plain language rather than medical jargon.
  • Reassure the patient that effective treatments exist and that recovery is possible.
  • Discuss the importance of early intervention in preventing worsening symptoms.

Task 3: Develop a management plan that includes evidence-based treatment options.

The competent candidate should:

  • Offer psychological therapy as first-line treatment (e.g., trauma-focused cognitive behavioural therapy [TF-CBT], eye movement desensitisation and reprocessing [EMDR]).
  • Address medication options (e.g., SSRIs like sertraline or paroxetine) if symptoms are moderate to severe or therapy is not accessible.
  • Discuss lifestyle interventions, such as exercise, sleep hygiene, and avoiding alcohol misuse.
  • Provide information on veteran-specific services if applicable, such as Open Arms – Veterans & Families Counselling.
  • Arrange follow-up appointments to monitor progress.

Task 4: Address patient concerns and encourage engagement with treatment.

The competent candidate should:

  • Reassure the patient that seeking help is a strength, not a weakness.
  • Discuss confidentiality concerns, ensuring that seeking treatment will not automatically impact employment.
  • Explore and validate reluctance about therapy, using motivational interviewing techniques.
  • Offer written information or referrals to support groups or peer support programs.

SUMMARY OF A COMPETENT ANSWER

  • Builds rapport and trust, allowing the patient to express concerns freely.
  • Takes a comprehensive history, including trauma triggers and impact on daily life.
  • Provides a clear, empathetic explanation of PTSD, avoiding medical jargon.
  • Discusses evidence-based treatment options, including therapy and medication.
  • Addresses stigma, confidentiality concerns, and barriers to treatment engagement.
  • Creates a structured management plan, ensuring follow-up and patient safety.

PITFALLS

  • Failing to explore trauma history sensitively, leading to patient withdrawal.
  • Over-medicalising PTSD without discussing psychological therapy as first-line treatment.
  • Not screening for self-harm or suicide risk, missing urgent safety concerns.
  • Dismissing concerns about stigma, making the patient reluctant to seek help.
  • Lack of cultural competence, especially if the patient is a veteran or from an at-risk population.
  • Not arranging follow-up, resulting in poor continuity of care.

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, concerns, expectations of healthcare, and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers relevant history, including risk factors and psychosocial factors.
2.2 Identifies key symptoms and red flags.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises PTSD and differentiates it from other conditions (e.g., depression, generalised anxiety disorder).
3.3 Uses clinical reasoning to formulate a patient-centred diagnosis.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan, including psychological therapy and medication if needed.
4.2 Engages the patient in shared decision-making.

5. Preventive and Population Health

5.1 Provides education about PTSD and early intervention.
5.2 Encourages engagement with peer support services.

6. Professionalism

6.1 Maintains confidentiality and addresses stigma concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Provides referrals to appropriate services, such as psychologists, psychiatrists, and veteran support services.

9. Managing Uncertainty

9.1 Manages reluctance about treatment and addresses barriers to care.

10. Identifying and Managing the Patient with Significant Illness

10.1 Screens for suicide risk and ensures a safety plan is in place.

Competency at Fellowship Level

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