Psych Vivas · Specialty psychiatry — sleep medicine interface
Insomnia disorder — structured clinical viva
Fellowship viva on chronic insomnia disorder: 3P model, CBT-I, hypnotic risk, OSA, and deprescribing.
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Target exams
FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar in clinic. A 58-year-old man with residual GAD and depression has taken temazepam nightly for 5 years. He wants a stronger tablet. ISI is high, he extends time in bed to 10 hours, clock-watches, and drinks wine most nights. BMI 34, snoring present, one fall last year. Discuss diagnostic hierarchy, Spielman 3P/hyperarousal framing, why long-term benzodiazepines are problematic, CBT-I components and cautions, OSA work-up, and a safe deprescribing plan.
Interpretation
Reveal interpretationShowHide
This is chronic insomnia disorder with residual anxiety/depression, long-term benzodiazepine use, clear perpetuating behaviours (extended TIB, clock-watching, alcohol), fall risk, and possible OSA. The request for a stronger hypnotic is the wrong vector — deprescribe, start CBT-I, and evaluate OSA.[1][2][6]
References6ShowHide
- [1]Glass J, Lanctot KL, Herrmann N, et al. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits BMJ, 2005.PMID 16284208
- [2]Qaseem A, Kansagara D, Forciea MA, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians Ann Intern Med, 2016.PMID 27136449
- [3]Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline J Clin Sleep Med, 2021.PMID 33164742
- [4]Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults J Clin Sleep Med, 2017.PMID 27998379
- [5]Wilson S, Anderson K, Baldwin D, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update J Psychopharmacol, 2019.PMID 31271339
- [6]Buysse DJ Insomnia JAMA, 2013.PMID 23423416