Cases/Mental Health

Software Engineer Waking At 4am Requesting Sleeping Tablets — Free SCA Practice Case

Software engineer waking at 4am requesting sleeping tablets

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Adam Fletcher

Age

34 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"I keep waking up at 4am with my mind racing and I can't get back to sleep. I'm exhausted. I think I just need some sleeping tablets."

Medical Records

●PMH: Nil significant.
●Medications: None.
●Allergies: NKDA.
●Recent contact: No recent consultations.

Patient Script

For the friend playing the patient role

Character Overview: You are Adam, a 34-year-old software engineer. You have been waking at 4am for weeks with your mind racing, and you are shattered. You have come asking for sleeping tablets. You are initially reluctant to say why your mind is racing, but the truth is you have run up serious debts through online gambling, which you have hidden from your partner, and the worry wakes you every night. You will disclose the gambling only if the doctor asks sensitively about what is on your mind. Your mood in the daytime is largely okay; it is the night-time rumination and the secret that are the problem.

Opening Sentence: "Hi Doctor. For a few weeks now I've been waking up at about 4 in the morning, wide awake, mind racing, and I just can't drop off again. I'm exhausted at work. I've tried everything and nothing works — I think I really just need some sleeping tablets to break the cycle."

History if Asked (Data Gathering Phase)

●The sleep problem: "I fall asleep fine, but I wake around 4am every night with my brain going a hundred miles an hour, and that's me awake for the day. It's been weeks."
●Daytime mood: "During the day I'm okay, actually — I function, I'm not especially down. It's the nights."
●What's on his mind (only if asked sensitively): "It's… money worries, mainly. [hesitates] Honestly? I've got into a mess with online gambling. I've run up debts I've hidden from my partner. That's what wakes me — the panic about it."
●The gambling (if explored): "It started as a bit of fun, football bets, then online casinos. I've been chasing losses, betting more to try to win it back, borrowing to cover it. It's out of control and I can't stop, even though I know I should."
●Why he wants tablets: "I just want to sleep. I thought sleeping tablets would sort the immediate problem so I can cope."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Adam sees the problem as insomnia to be fixed with tablets; he has compartmentalised the gambling as a separate, shameful secret rather than the cause. "In my head the problem is that I can't sleep, and tablets fix that. I've been trying not to connect it to the gambling."
●Concerns: His real worries are the debt, the fear of his partner finding out, and a growing sense he cannot control the gambling; there is shame and some hopelessness. "I'm terrified of my partner finding out, drowning in the debt, and scared I can't stop even when I want to."
●Expectations: He expects a prescription for sleeping tablets. "I came for sleeping tablets — I wasn't planning to tell anyone about the rest."

If Asked — Medical History, Gambling, and Risk (approached sensitively)

The patient answers these only when directly and sensitively asked.

●If asked about sleep hygiene (caffeine, screens, routine, alcohol): "Lots of coffee, on screens late — I'm often on my phone gambling into the night, which probably doesn't help."
●If asked about daytime low mood, anhedonia: "Not really depressed in the day — it's more the night-time anxiety and the secret."
●If asked about the extent and impact of the gambling: "Thousands in debt, hidden from my partner, borrowing to cover it, chasing losses. It's affecting everything."
●If asked about attempts to stop / control: "I've tried to stop loads of times and can't. I always go back."
●If asked, sensitively, about thoughts of self-harm or that life isn't worth living: "There have been moments, when the panic's bad, where I've thought I can't see a way out… but I wouldn't act on it. I've got my partner." (Passive thoughts, no plan, protective factors. Assess sensitively; no method detail sought or given.)
●If asked about other impulsive/risky behaviours: "No, nothing else — no drugs, drinking's normal. It's just the gambling."
●If asked about work/relationship impact: "I'm distracted at work, and I'm lying to my partner constantly, which is eating me up."

Responses to Management (The Negotiation Phase)

●If the Doctor uncovers and names the gambling as the real issue: "You're right — it's not really the sleep, is it? It's the gambling and the debt underneath it." (The tested point is looking beyond the presenting request to the underlying cause.)
●If the Doctor declines sleeping tablets and explains why: "So you won't give me sleeping tablets? But I'm desperate to sleep." (The tested point is declining hypnotics appropriately — explaining dependence/tolerance and that they won't address the cause, especially in someone with an addiction — while offering effective alternatives.)
●If the Doctor signposts gambling support: "There's actual help for gambling? I thought I just had to sort it myself." (The tested point is signposting specialist gambling and debt support.)
●If the Doctor discusses telling his partner / support: "I don't know how I'd even begin to tell my partner. But keeping it secret is killing me."
●If the Doctor safety-nets and arranges follow-up: "What do I do if it all gets on top of me before I see you again?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Look Beyond the Presenting Request

●A request for sleeping tablets often conceals an underlying cause — stress, anxiety, depression, or, as here, an addiction and debt. The key skill is exploring why the patient cannot sleep rather than treating "insomnia" at face value.
●Early-morning waking with a racing mind points to anxiety/rumination (and can also be a biological feature of depression).

Gambling Disorder

●Gambling disorder is a recognised behavioural addiction: features include loss of control, chasing losses, borrowing/hiding debt, repeated failed attempts to stop, and impact on work and relationships.
●It carries an elevated risk of depression and suicide, and is often hidden through shame — sensitive, non-judgemental enquiry is essential.

Declining Hypnotics Appropriately

●Benzodiazepines and Z-drugs are not appropriate for chronic insomnia driven by an underlying problem: they cause dependence and tolerance, do not address the cause, and are particularly hazardous in a person with an addiction.
●Decline with a clear rationale and offer effective alternatives.

Effective Management of Insomnia

●Sleep-hygiene measures, reducing caffeine and night-time screen/phone use, relaxation techniques, and CBT for insomnia (CBT-I) are the evidence-based approach — treating the cause alongside.

Signposting Addiction and Debt Support

●Signpost gambling-specific support (e.g. GamCare / National Gambling Helpline, Gamblers Anonymous, NHS gambling clinics/services) and debt advice (e.g. StepChange, Citizens Advice, National Debtline) — the core interventions.

Associated Mood and Risk

●Screen for and manage associated anxiety/depression, and assess suicide risk sensitively (without naming methods), responding proportionately with urgent support if needed.

Support and Secrecy

●Whether to disclose to a partner is the patient's choice; acknowledge the toll of secrecy and the value of support, without pressure. Provide follow-up and safety-netting.

Common Candidate Mistakes in This Case

●Treating the insomnia at face value: prescribing (or focusing only on) sleep without uncovering the gambling.
●Prescribing hypnotics: giving benzodiazepines/Z-drugs to someone with an addiction and an untreated cause.
●Judgemental enquiry: asking about gambling in a way that shames the patient, so he disengages.
●Not signposting support: missing gambling and debt services — the key interventions.
●Missing mood/risk: failing to screen for depression and to assess suicide risk sensitively.

Free MRCGP SCA practice case for GP registrars covering Software Engineer Waking At 4am Requesting Sleeping Tablets — Mental Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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