History Taking · Advanced · Psychiatry

Nightmares and Avoidance Following Trauma

Practise this PLAB 2 history taking station on Post-Traumatic Stress Disorder. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in primary care. Reginald Parks, a 35-year-old man, has come to see you after being referred by occupational health at his workplace. He was involved in a serious motor vehicle accident two years ago and has been experiencing ongoing symptoms including nightmares, flashbacks, and avoidance of certain situations. Please take a focused history and discuss assessment and management options for his symptoms.

Background notes: PMH: Broken left leg, Crushed left hand, MVA trauma 2 years ago

What this station tests

  • Four PTSD symptom clusters: re-experiencing, avoidance, negative cognitions, hyperarousal
  • Trauma-focused CBT or EMDR as first-line: not standard CBT, must be trauma-specific
  • Do not prescribe benzodiazepines: can worsen PTSD and create dependence
  • Alcohol as self-medication: common in PTSD, worsens symptoms
  • Timeline: PTSD diagnosed after 1 month, acute stress disorder before 1 month

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

PTSD requires the candidate to identify the four symptom clusters (re-experiencing, avoidance, negative cognitions, and hyperarousal) following a traumatic event. Mr Parks is 35, a delivery driver who was in a serious RTA 6 months ago. His occupational health referred him. Open with: 'Mr Parks, tell me what has been happening since the accident.'

Core approach

Identify the four PTSD symptom clusters. Re-experiencing: nightmares about the crash (3 to 4 per week), flashbacks (feeling like he is back in the van), intrusive memories triggered by traffic sounds. Avoidance: cannot drive (will not get in a van), avoids the road where the accident happened, avoids watching news about RTAs. Negative cognitions: guilt ('I should have seen the other car'), feels the world is unsafe, feels detached from family. Hyperarousal: exaggerated startle response (jumps at loud noises), poor sleep, irritability, difficulty concentrating.

Timeline: symptoms for 6 months (PTSD diagnosed after 1 month; acute stress disorder before 1 month). He is unable to work (delivery driver who cannot drive). His relationship is strained. He is drinking more to cope (common self-medication, must be addressed).

Screen for comorbidities: depression (common with PTSD), suicidal ideation, substance misuse.

Closing and safety netting

Treatment per NICE: trauma-focused CBT or EMDR (eye movement desensitisation and reprocessing) are first-line. Not standard CBT: it must be trauma-focused. SSRI (sertraline or paroxetine) if psychological therapy is declined or insufficient. Do not prescribe benzodiazepines (can worsen PTSD and create dependence).

Address his work: occupational health can support a phased return. Driving will be addressed through therapy. Address alcohol: 'Alcohol may feel helpful in the short term but it worsens sleep, nightmares, and mood.' PTSD UK charity for support. Safety net: if flashbacks become overwhelming, suicidal thoughts develop, or alcohol use escalates, come back urgently. Follow-up in 2 weeks.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for post-traumatic stress disorder. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: All four clusters identified. Timeline confirmed (>1 month). Comorbidities screened (depression, alcohol). Functional impact (unable to work, relationship strain).

Costs marks: Missing symptom clusters. Not confirming timeline. Not screening alcohol.

Domain 2 (Primary focus)

Scores well: Trauma-focused CBT or EMDR recommended. No benzodiazepines. SSRI if needed. Alcohol addressed. Occupational health. PTSD UK.

Costs marks: Prescribing benzodiazepines. Standard CBT. Not addressing alcohol.

Domain 3 (Throughout)

Scores well: Acknowledging the trauma and its ongoing impact. Not pushing him to 'move on.' Validating his symptoms as a normal response to abnormal events.

Costs marks: Minimising the trauma. Suggesting he should be 'over it.' Not validating.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Prescribing benzodiazepines: these are contraindicated in PTSD, worsen symptoms and create dependence
  2. Referring for standard CBT: PTSD requires trauma-focused CBT or EMDR specifically
  3. Not screening for alcohol misuse: self-medication with alcohol is extremely common in PTSD

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the post-Traumatic stress disorder history in this PLAB 2 station?

PTSD requires the candidate to identify the four symptom clusters (re-experiencing, avoidance, negative cognitions, and hyperarousal) following a traumatic event. Mr Parks is 35, a delivery driver who was in a serious RTA 6 months ago. His occupational health referred him.

What are examiners marking in this post-Traumatic stress disorder station?

Marks are won for: All four clusters identified. Timeline confirmed (>1 month). Comorbidities screened (depression, alcohol). Functional impact (unable to work, relationship strain). Marks are lost for: Missing symptom clusters. Not confirming timeline. Not screening alcohol.

What is the most common mistake candidates make in this post-Traumatic stress disorder station?

Prescribing benzodiazepines: these are contraindicated in PTSD, worsen symptoms and create dependence. Another frequent error: Referring for standard CBT: PTSD requires trauma-focused CBT or EMDR specifically.

How do I prepare for this station if I have not managed post-Traumatic stress disorder in clinical practice?

This station rewards process over personal experience. The skill being assessed: Trauma-focused CBT or EMDR as first-line: not standard CBT, must be trauma-specific. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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