Explain CBT-I and hypnotic taper for chronic insomnia disorder — CASC communication station

Station brief

Format. Communication station, approximately 7–10 minutes after reading. You are the psychiatry registrar in outpatient clinic. [1]

Candidate instructions. Explain chronic insomnia disorder as treatable, why CBT-I is first-line (not “just hygiene”), what the main techniques involve, why long-term hypnotics are not ideal, negotiate a collaborative short-term medication plan with deprescribing, and check understanding. Address anxiety about not sleeping. The examiner plays the patient. [1][2][3]

Candidate scenario

The patient has had sleep-onset insomnia for 2 years, uses zolpidem most nights, and wants ongoing repeats. Brief OSA screen negative. Mild GAD, no active suicidal ideation. Open to “evidence” but sceptical of psychology. Digital CBT-I is available in your service. [5]

Marking domains

• Empathy and agenda-setting without colluding with indefinite hypnotic escalation
• Accurate plain-language hyperarousal / learned insomnia model
• CBT-I explained as structured therapy with named components (stimulus control, sleep restriction, cognitive work)
• Evidence tone: guidelines first-line; meta-analysis supports benefit; digital option if acceptable [1][2][3][5]
• Honest discussion of tolerance, dependence, next-day effects; medications can help short-term but durability favours CBT-I (Morin-type teaching) [4]
• Collaborative taper plan, safety-net, teach-back

Common fails

• Lecturing without empathy
• Agreeing to indefinite high-dose hypnotics
• Describing only “no screens and warm milk”
• Ignoring occupational anxiety about sleepless nights
• Failing to name CBT-I components or negotiate a hypnotic taper when guidelines put CBT-I first. [1][2][3]