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Please take a history from Jackie about what’s brought her to the GP and perform a full mental state examination. She has cancelled and remade this appointment on three separate occasions in the last week.

A lot of this case is going to come from body language and non-verbal communication so this is going to have both your ICE but also some behaviour cues to help. Speak quietly and in perfunctory sentences. Avoid eye contact, either looking at the ground or focussing on your hands. Give limited information making it obvious you’re holding something back. When pressed on it, snap angrily then get upset at the fact that you snapped. Be teary and easily startled throughout. For ICE you should make sure you’ve been directly asked these questions and only answer them if the student has developed a strong relationship with you by exploring HPC well.

Initially you just say that you think you’ve just started to drink excessively as a habit- you actually think you’re drinking to cope and try and drown out the thoughts. You’re worried that this will continue and that eventually you’ll spiral down so far you’ll become a recluse or kill yourself. You are scared of how much control your ex-husband still has in your life even after you had thought you’d managed to escape his grasp. You don’t expect anything from this, you’re pretty sure you’re too far gone for help at this point but its worth a shot.

History of Presenting Complaint You have come to the GP because you’re drinking too much alcohol and its getting in the way of your ability to think. You drink a bottle of wine over the course of three days, white wine approximately 11%. You do not take break days and instead find yourself drinking every day. You don’t really get angry when other people question your drinking since you don’t really have anybody else to notice it.

You’ve been isolating yourself more and more. You can’t really trust anyone else or yourself either. You’re scared that the people you care about might actually be there to hurt you and you’re even more scared of strangers. You haven’t left the house in over a week now except for this trip to the GP. Even then it took three attempts to work up the courage to leave the house. You don’t trust yourself to be normal outside since you’ve been getting worse and worse mood swings. Your best friend mentioned getting worried and you just shouted at her. You’re also exhausted since you’re getting no sleep at all, you feel like you can’t relax since you don’t feel safe. When you finally manage to fall asleep you get the worst nightmares. You’ve since added a second lock to the door.

You have been getting flashbacks to your ex-husband. He was a mean and violent drunk. You do wonder if there was anything you could’ve done or any way you could’ve been better so that he wouldn’t have hurt you. Sometimes you day dream about getting revenge but you don’t think you’ll be able to.

You’ve not had any suicidal thoughts. You’re feeling more and more detached from people. In fact, you’ve given up all your hobbies and barely talk to anyone now. You struggle to concentrate at times. You have not had any hallucinations.

This is a very difficult case for the student. Here the focus is on communication skills and ability to build a rapport with the patient. If they take a superficial history exclusively on alcohol despite the hints dropped by the patient then they have missed the point of the exercise. Additionally, if they probe too hard on this initial meeting they risk damaging the doctor patient relationship. A fine line indeed!

Appropriate differential diagnoses are PTSD, Depression with Agoraphobia, Complicated grief reaction, and Enduring personality change after trauma. These can be added to a degree of alcohol dependence as well.

Management plan should include continuing a strong doctor-patient relationship (since this can only be treated if the relationship is built on mutual trust), trauma-focused cognitive behavioural therapy, Eye Movement Desensitisation and Reprocessing (EMDR), stress management information, relaxation therapies and addressing the alcohol dependence. Drug treatment is second line and it is less useful for it to be mentioned at this point.

Example questions and answers:

What are risk factors for PTSD? Exposure to trauma or combat, refugee/asylum seeker status, first responder occupation, combat specific (duration of exposure, low morale, poor social support, lower rank, unmarried, low educational attainment, childhood adversity), previous psychiatric disorders.

Is PTSD the same for everyone? No it is not. Some people may develop some form of it following an event which self-resolves in 6 months. Others will only develop one of the three key symptoms (Hypervigilance, flashbacks and rumination). There is also a cultural

aspect to it which might lead to people presenting with medically unexplained symptoms rather than a direct psychological complaint.

Which neurotransmitter is involved in the fight or flight response? Adrenaline.