Psych CASC / OSCE · Specialty psychiatry — sleep medicine interface
Explain RLS diagnosis, iron, and treatment switch after dopamine-agonist augmentation — CASC communication station
MRCPsych/FRANZCP-style communication station: explain RLS and augmentation, iron rationale, α2δ switch, and collaborative safety plan without colluding with DA escalation.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes after reading. You are the psychiatry registrar in outpatient clinic. [1]
Candidate instructions. Explain the diagnosis of restless legs syndrome in plain language, what augmentation means, why increasing pramipexole is unhelpful, why iron matters despite normal energy levels, outline a collaborative switch toward an α2δ ligand with iron repletion, check understanding, and safety-net. The examiner plays the patient. [2][3][4]
Candidate scenario
The patient meets classic RLS criteria historically. On long-term pramipexole, symptoms now start earlier and involve the arms. They are anxious, sleep-deprived, and want a higher dose today. No active suicidal plan; ferritin 55 ng/mL this week. Open to evidence but fearful of change. [2][4]
Marking domains
- Empathy without colluding with dopamine-agonist dose escalation
- Accurate plain-language RLS criteria explanation [1]
- Clear explanation of augmentation (earlier, worse, spreads) [2]
- Iron rationale at RLS ferritin thresholds, not only anaemia [4]
- α2δ-first chronic strategy and evidence tone (lower augmentation risk vs higher-dose DA) [3][5][6]
- Collaborative taper/switch plan, teach-back, safety-net for mood/SI and impulse-control symptoms
Reveal assessor key
Open. “I can see sleep feels fragile and the legs are winning earlier in the day — that pattern actually tells us the current medicine may be making the circuit more sensitive, not that we simply need a bigger dose.” [2]
RLS model. The brain’s iron–dopamine sleep-movement system misfires in the evening: urge to move at rest, better when you walk, worse at night. Diagnosis is clinical. [1]
Augmentation. Starting earlier, spreading to arms, needing more drug is a known dopamine-agonist complication called augmentation. Raising the dose usually digs the hole deeper. [2][3]
Iron. Ferritin 55 is low for RLS care even if you are not anaemic; replacing iron can calm the circuit and is guideline-supported. [4]
Plan. Start iron pathway; introduce an α2δ medicine (e.g. pregabalin pathway) that treats RLS with far less augmentation risk; carefully reduce pramipexole with close follow-up; warn temporary fluctuation; written plan and emergency contacts if mood or sleeplessness crashes. [3][5][6]
Close. Teach-back of one key point (“higher pramipexole is not the fix”), follow-up timing, and impulse-control check (gambling/spending/sexual drive changes). [3]
References
- [1]Allen RP, Picchietti DL, Garcia-Borreguero D, et al. Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: updated International Restless Legs Syndrome Study Group (IRLSSG) consensus criteria Sleep Med, 2014.PMID 25023924
- [2]García-Borreguero D, Allen RP, Kohnen R, et al. Diagnostic standards for dopaminergic augmentation of restless legs syndrome Sleep Med, 2007.PMID 17544323
- [3]Garcia-Borreguero D, Silber MH, Winkelman JW, et al. Guidelines for the first-line treatment of restless legs syndrome/Willis-Ekbom disease, prevention and treatment of dopaminergic augmentation Sleep Med, 2016.PMID 27448465
- [4]Allen RP, Picchietti DL, Auerbach M, et al. Evidence-based and consensus clinical practice guidelines for the iron treatment of restless legs syndrome/Willis-Ekbom disease in adults and children Sleep Med, 2018.PMID 29425576
- [5]Allen RP, Chen C, Garcia-Borreguero D, et al. Comparison of pregabalin with pramipexole for restless legs syndrome N Engl J Med, 2014.PMID 24521108
- [6]Silber MH, Buchfuhrer MJ, Earley CJ, et al. The Management of Restless Legs Syndrome: An Updated Algorithm Mayo Clin Proc, 2021.PMID 34218864