CCE-CBD-020

Examiner Only Information

Questions

Q1. How would you differentiate primary insomnia from secondary sleep disorders?

• Prompt: What history features help distinguish different causes of sleep disturbance?
• Prompt: When would you consider further investigations, such as a sleep study?

Q2. What non-pharmacological strategies would you recommend for Mark’s sleep disturbance?

• Prompt: What evidence-based behavioural interventions should be prioritised?
• Prompt: How would you introduce cognitive behavioural therapy for insomnia (CBT-I)?

Q3. How would you counsel Mark on the role of medications for sleep?

• Prompt: What are the risks and benefits of using sedative-hypnotics?
• Prompt: What alternatives to benzodiazepines or Z-drugs should be considered?

Q4. What lifestyle modifications should Mark make to improve sleep hygiene?

• Prompt: How does alcohol affect sleep architecture?
• Prompt: What daily habits should he adopt or avoid?

Q5. When would you consider referral or specialist input?

Prompt: When would a sleep study be indicated?

Prompt: What red flags suggest the need for a sleep physician or psychologist review?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you differentiate primary insomnia from secondary sleep disorders?

The competent candidate should:

• Obtain a detailed sleep history:
  • Primary insomnia: Difficulty initiating or maintaining sleep, no identifiable medical or psychiatric cause.
  • Secondary insomnia: Linked to anxiety, depression, obstructive sleep apnoea (OSA), restless legs syndrome, or substance use.
• Assess daytime symptoms:
  • OSA indicators: Snoring, witnessed apnoeas, excessive daytime sleepiness.
  • Restless legs syndrome: Uncomfortable leg sensations relieved by movement.
  • Anxiety/depression: Ruminating thoughts, early morning waking.
• Consider further investigations:
  • Sleep study (polysomnography) if OSA suspected.
  • Epworth Sleepiness Scale (ESS) to assess daytime sleepiness.
  • Mental health screening (K10, DASS-21) if anxiety/depression suspected.

---

Q2: What non-pharmacological strategies would you recommend for Mark’s sleep disturbance?

The competent candidate should:

• Cognitive Behavioural Therapy for Insomnia (CBT-I) as first-line treatment:
  • Sleep restriction therapy: Reducing time in bed to consolidate sleep.
  • Stimulus control: Associating bed with sleep only.
  • Relaxation training: Deep breathing, meditation.
  • Cognitive therapy: Addressing unhelpful thoughts about sleep.
• Sleep hygiene education:
  • Consistent sleep-wake times.
  • Avoiding caffeine, screens, and alcohol before bed.

---

Q3: How would you counsel Mark on the role of medications for sleep?

The competent candidate should:

• Explain that medications are not first-line due to risk of dependence.
• Discuss safer alternatives:
  • Short-term melatonin for sleep initiation.
  • Sedating antidepressants (e.g., mirtazapine) if comorbid anxiety/depression present.
• Highlight risks of benzodiazepines and Z-drugs:
  • Dependence, tolerance, next-day drowsiness.

---

Q4: What lifestyle modifications should Mark make to improve sleep hygiene?

The competent candidate should:

• Reduce alcohol intake, as it disrupts sleep architecture.
• Increase physical activity (but avoid intense exercise before bed).
• Establish a bedtime routine (relaxation techniques, avoiding screens).

---

Q5: When would you consider referral or specialist input?

The competent candidate should:

• Refer to a sleep specialist if:
  • OSA suspected (loud snoring, apnoeas, excessive daytime sleepiness).
  • Severe insomnia despite CBT-I.
• Refer to a psychologist if significant anxiety/depression present.

---

SUMMARY OF A COMPETENT ANSWER

• Differentiates primary insomnia from secondary causes (OSA, mental health).
• Prioritises CBT-I over pharmacological treatments.
• Discusses risks of benzodiazepines and promotes safer alternatives.
• Encourages sleep hygiene and lifestyle modifications.
• Recognises indications for referral to sleep or mental health specialists.

---

PITFALLS

• Prescribing sedatives as first-line treatment without addressing behavioural strategies.
• Failing to assess for secondary causes like OSA or anxiety.
• Ignoring alcohol’s impact on sleep quality.
• Not considering referral when insomnia is resistant to initial treatment.

---

REFERENCES

• RACGP Sleep Disturbance Guidelines
• National Institutes of Health on Insomnia Management
• Sleep Health Foundation on CBT for Insomnia

---

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 Communicates clearly and empathetically with the patient.
1.3 Engages the patient in discussing concerns and expectations about treatment.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured and hypothesis-driven sleep history.
2.3 Identifies secondary causes of sleep disturbance.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between primary and secondary insomnia.
3.5 Uses clinical reasoning to determine the need for further investigations.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a sleep management plan with behavioural interventions.
4.3 Uses pharmacological treatments appropriately.

5. Preventive and Population Health

5.2 Provides lifestyle and sleep hygiene education.

6. Professionalism

6.3 Addresses patient concerns about medication use.

7. General Practice Systems and Regulatory Requirements

7.2 Ensures appropriate prescribing of sleep medications.

9. Managing Uncertainty

9.1 Uses appropriate investigations for persistent sleep disturbances.

10. Identifying and Managing the Patient with Significant Illness

10.3 Recognises when specialist referral is required.

Competency at Fellowship Level

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