Joel Plymouth

Age: 28 years old male

Full Case

Station List
Doctor
Patient
Examiner

Patient’s Data​

Patient’s name: Joel Plymouth

Age: 28-year-old male

Past medical history

  • Nil
  • Patient serves in the Royal Navy

Drug and Allergy History

  • Nil 

Recent notes/consultation

  • Nil

Patient booked a telephone appointment with the GP to discuss some concerns

Patient's Story (Role player’s brief)

Patient’s Story 

You are Joel Plymouth, a 28-year-old male serving in the Royal Navy as an accounts officer. You have booked a telephone appointment with the GP because you are struggling to sleep and need help.

Opening statement: “Hi doctor, I just can’t sleep anymore. It’s getting unbearable. Can I have a sleeping tablet, please?”

IF ASKED TO EXPLAIN FURTHER: 

You returned from active duty in Afghanistan around 4 months ago, where your best friend was killed in combat. Since then, you’ve been experiencing increasing psychological distress.

You are having severe sleep difficulties, particularly over the last 2 months. You struggle to fall asleep and wake frequently with intense nightmares and flashbacks related to your experiences during the war. These symptoms are affecting your ability to function both at work and in your personal life.

ONLY SAY BELOW IF ASKED: 

You feel constantly on edge, hypervigilant, and emotionally numb. You find it difficult to connect with others, particularly your girlfriend, and feel guilty for not being able to love her the way you used to. Your mood has been low because of everything you’ve been experiencing.

Due to your deteriorating mental state, you have voluntarily handed in your gun, as you don’t feel mentally fit to handle it. However, you do not have any suicidal thoughts.

Social History: You do not smoke, do not drink alcohol, and do not use recreational drugs. You drive regularly but do not experience drowsiness while driving. You live with your girlfriend who is supportive 

Ideas: You suspect these issues are related to your time in the war

Concerns: You feel distraught and are not able to perform your duties in the Royal Navy due to lack of sleep and low mood.

Expectations: You’re hoping the GP can prescribe sleeping tablets to help you rest.

Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.

Marking Scheme

Data Gathering and Diagnosis 

  • Ask about his current sleeping pattern (to understand the nature and severity of the problem)
  • Ask whether he has difficulty falling asleep, staying asleep, or both (to help characterise insomnia symptoms)
  • Ask about daytime sleepiness or fatigue (to assess functional impact)
  • Recognise that symptoms are suggestive of Post-Traumatic Stress Disorder (PTSD)
  • Ask about any triggers or thoughts that prevent him from sleeping (to identify associations with trauma or anxiety)
  • Ask about flashbacks or intrusive thoughts related to the traumatic event 
  • Ask if he experiences nightmares linked to the war 
  • Ask whether he avoids situations or reminders of the traumatic event 
  • Ask if he feels emotionally numb or detached from others
  • Ask if he feels guilt or self-blame, particularly in relation to the death of his friend (to explore trauma-related beliefs)
  • Ask about his overall mood (to assess for comorbid depression)
  • Ask if he still has interest or pleasure in usual activities 
  • Ask if he has experienced any suicidal thoughts or self-harm
  • Ask how these symptoms are affecting his life, including his work and personal relationships
  • Ask if he drives, and whether his sleep issues affect his ability to drive safely (for safety and DVLA implications)
  • Since he is in the armed forces, ask if he currently has access to a firearm and whether he has returned it voluntarily (patients with mental health concerns should not have access to firearms — this has legal and safeguarding implications)
  • Ask about smoking, alcohol, and recreational drug use 
  • Ask what strategies or remedies he has already tried to manage his sleep
  • Make a working diagnosis of Post-Traumatic Stress Disorder (PTSD)

Example of explanation to patient​

 Joel, thank you for sharing everything with me. I can only imagine how difficult this must be for you right now, and I want to acknowledge your courage in speaking about it. It sounds like you’re going through a very challenging time.

From what you’ve told me, it seems you may be experiencing symptoms of Post-Traumatic Stress Disorder (PTSD). This is a recognised mental health condition that can develop after experiencing or witnessing a traumatic event—such as your time in Afghanistan and the loss of your close friend. Common symptoms include flashbacks, nightmares, emotional numbness, low mood, hypervigilance, and sleep difficulties, all of which you’re currently facing.

I want to reassure you that these are natural responses to trauma and do not mean you’re weak or incapable. Seeking help, like you’re doing now, is a very important first step, and the good news is that PTSD is treatable.

In terms of next steps, we have a few options:

First, we can try some sleep hygiene strategies to help regulate your sleep naturally. These include:

  • Going to bed and waking up at the same time every day, even on weekends
  • Avoiding screens (phones, laptops, TVs) for at least an hour before bedtime
  • Not forcing sleep—if you’re unable to sleep, try stepping away and returning to bed when sleepy
  • Removing clocks from view to avoid clock-watching
  • Limiting naps during the day so you feel more tired at night
  • Exercising regularly during the day to help your body rest better at night

Would you be willing to try these measures first?

If you feel sleep is still unmanageable, we can consider a short course of a sleeping tablet called zopiclone. This would only be prescribed for a maximum of 7 days initially and ideally, taken on alternate nights while you’re practising the sleep hygiene techniques. This is because zopiclone can become addictive and lead to dependence or worsen sleep issues if used long-term.

I’d also like to refer you to a specialist mental health service, in your case, through the veterans’ priority pathway, where you’re likely to be seen more quickly. You would likely be offered Trauma-Focused talking therapy also known as Cognitive Behavioural Therapy (CBT), which has strong evidence for helping people with PTSD.

While we wait for that referral, we could consider starting an antidepressant to help stabilise your mood and reduce anxiety. We can discuss this further and decide together if this feels right for you.

You also mentioned that your symptoms are affecting your work. I can provide a supporting letter for your employer to help facilitate adjustments at work or some time off if needed. It’s important that you feel supported, not pressured, while recovering.

In addition to professional treatment, there are support groups specifically for veterans that can offer understanding, guidance, and a sense of community. I recommend looking into:

Combat Stress – a UK charity offering mental health support for veterans

Veterans UK – a government service providing practical advice and emotional support for former service personnel

Management

Management

  • Offer screening using the Trauma Screening Questionnaire (TSQ) to support a working diagnosis of PTSD.
  • Advise on sleep hygiene measures, including maintaining a comfortable sleep environment, going to bed only when sleepy, waking at the same time daily (including weekends), doing relaxation exercises in the evening, avoiding screens before bed, and avoiding exercise close to bedtime while encouraging it earlier in the day.
  • Offer a short course of zopiclone, prescribing 7 tablets to be taken on alternate nights over a two-week period. Explain that this is for short-term relief only and that long-term use is not recommended due to the risk of dependence and tolerance.
  • Inform him that zopiclone can cause dizziness, and if he experiences this, he should not drive.
  • Refer him under the veterans’ priority scheme to a specialist for assessment and trauma-focused cognitive behavioural therapy (CBT).
  • While awaiting specialist input, offer drug treatment options if he is open to it, including an SSRI or venlafaxine.
  • If medication is initiated, inform him about the possible risk of increased suicidal thoughts in the initial phase. Arrange to review him in one week and continue with weekly reviews for the first month. 
  • Offer support with work-related issues, which may include providing a fit note outlining amended duties, reduced hours, or recommending a period of sick leave if needed.
  • Provide the contact number for the local crisis team in case he experiences a deterioration in his mental health or needs urgent support.
  • Inform him about veteran-specific support groups, including Combat Stress and Veterans UK, which can provide emotional and practical assistance.
  • Safety net by asking about suicidal thoughts before concluding the consultation and arrange follow-up in 1–2 weeks to monitor progress and review ongoing needs.

Learning point from this station: ​

This station demonstrates the importance of identifying and managing Post-Traumatic Stress Disorder (PTSD), particularly in military veterans, within the primary care setting. PTSD may initially present with non-specific symptoms such as sleep disturbance, low mood, or poor functioning, and may not be immediately volunteered by the patient. A sensitive, structured approach to history-taking is vital to uncover the underlying trauma.

Key learning points include:

Recognise the core features of PTSD: flashbacks, nightmares, hypervigilance, emotional detachment, avoidance behaviours, and guilt.

Be aware that PTSD commonly co-exists with other mental health conditions such as depression, anxiety, alcohol or substance misuse, and gambling-related harms.

Understand that armed forces veterans with service-related PTSD are eligible for expedited referral to secondary care under the veterans’ priority scheme.

Referral to a mental health specialist should be offered early to confirm the diagnosis of PTSD. Once confirmed, specialists typically offer Trauma-Focused Cognitive Behavioural Therapy (CBT) or Eye Movement Desensitization and Reprocessing (EMDR) as part of treatment.

Consider prescribing antidepressants such as venlafaxine or an SSRI in adults if:

  • The person prefers drug treatment,
  • The person declines psychological therapy,
  • Or if referral is significantly delayed.

Be aware that SSRIs and SNRIs are associated with increased risk of suicidal ideation and self-harm in a minority of patients under 30 years of age. Patients in this group should be reviewed within 1 week of starting medication and monitored every week for the first month.

As per NICE, drug treatments should not be offered in primary care for PTSD in children and young people under 18 years.

For sleep disturbances, advise on sleep hygiene as a first step. If needed, a short-term course of a hypnotic (e.g., zopiclone) may be considered.

Hypnotics should only be used for short durations, as they can worsen nightmares; if this occurs, the medication should be stopped immediately.

Assess and support functioning at work by offering fit notes, recommending amended duties, or advising a period of time off.

Always carry out a risk assessment, provide the crisis team contact, and arrange close follow-up (1–2 weeks) to ensure safety.

Signpost to veteran-specific support services, including Combat Stress and Veterans UK, which provide tailored emotional and practical support.

Firearms and public safety considerations:

Patients with access to firearms and suspected or confirmed mental health conditions should be sensitively asked whether they still have access to weapons.

GPs should consider whether any mental or physical condition affects the individual’s ability to safely possess a firearm or shotgun, now or in the future.

While maintaining patient confidentiality, GPs also have a duty to protect public safety. If a patient poses a risk to themselves or others, information may be shared with police:

  • With the patient’s consent
  • On public interest grounds
  • Or if legally required in rare cases

Patients should be encouraged to contact the police regarding their firearms licence, as decisions about revocation are made by the police.

If the individual is an armed forces member, they should also be advised to inform their superior officers, as the supervision and regulation of firearms in the military is handled by the command hierarchy, including senior officers and specialised personnel.

Further reading