Ethics · Intermediate · Ethics

Insomnia with Underlying Domestic Violence

Practise this PLAB 2 ethics station on Insomnia (Domestic Abuse). 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 working in a GP clinic and you are seeing Mrs Ching Yeoh, a 42-year-old woman, who has come in with a three-month history of severe insomnia. She says she cannot sleep, wakes frequently, and feels exhausted. She initially attributes this to work stress. As you explore further, asking open questions about her life, relationships, and wellbeing, it becomes apparent that there are significant relationship problems at home. Through careful, sensitive questioning, you uncover that she is experiencing emotional and financial abuse from her husband. She is reluctant to disclose initially but gradually reveals more as she feels safer. Please explore the underlying causes of her insomnia, identify the abuse, demonstrate safeguarding awareness, and discuss options for support.

Background notes: PMH: perimenopause symptoms starting

What this station tests

  • Recognising domestic violence presenting as a different complaint: insomnia as a marker of hypervigilance
  • Retirement as a risk factor: sudden increased proximity and loss of the victim's safe time alone
  • Coercive control: monitoring movements, finances, phone, isolating from support network
  • Not prescribing benzodiazepines in a dangerous domestic situation: reduced alertness increases vulnerability
  • Creating safe space for disclosure without forcing it

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself. Establish the ethical issue and your role.
  • 1-3 min — Explore Perspective: Listen to patient/relative perspective. Understand their reasoning and concerns.
  • 3-5 min — Ethical Framework: Apply ethical principles: autonomy, beneficence, non-maleficence, justice. Reference relevant guidelines (GMC, Mental Capacity Act).
  • 5-7 min — Negotiate and Plan: Find common ground. Explain your professional obligations. Involve MDT where appropriate. Document plan.
  • 7-8 min — Closing: Summarise agreed position. Outline next steps. Offer further discussion.

Consultation approach

The opening

Domestic violence often presents as a different complaint (insomnia, headache, depression). The candidate must recognise the clues and create space for disclosure. Mrs Yeoh is 42, presenting with insomnia. Her husband recently retired (increased proximity is a risk factor). Open with: 'Mrs Yeoh, tell me about the sleep problems and what else has been going on at home.'

Core approach

Look for clues that the insomnia has a deeper cause. She is anxious, evasive about home life, her husband retired 3 months ago (sudden increased proximity), she is hypervigilant at night (listening for him). Ask sensitively: 'Sometimes sleep problems are connected to feeling unsafe at home. Is there anything you want to tell me about your relationship?'

If she discloses: follow the same pathway as Case 195. Believe, validate, assess safety, document safely, offer support without pressure. If she does not disclose: do not force, but leave the door open: 'If there is ever anything you want to discuss about your home situation, I am here.'

Assess for coercive control: does he monitor her movements, finances, phone? Does she need permission to leave the house? Has he isolated her from friends and family? Coercive control is a criminal offence.

Closing and safety netting

Treat the presenting complaint (insomnia) but address the underlying cause. Sleep hygiene alone will not work if she is lying awake because she is frightened. If she has disclosed: safety plan, helpline, safe follow-up. If she has not: treat the insomnia symptomatically, arrange follow-up, and maintain the safe space for future disclosure.

Do not prescribe benzodiazepines (reduced alertness in a dangerous situation is harmful). Safety net: 'If you ever feel in immediate danger, call 999.' Follow-up in 2 weeks with a safe appointment.

How examiners mark this station

Examiners will assess your ethical reasoning and interpersonal skills. Domain 2 (Clinical Management) is primary: marks for applying an ethical framework, referencing relevant legislation and guidelines, and reaching a reasoned position. Domain 3 (Interpersonal Skills) is equally weighted: marks for non-judgmental exploration, empathic communication, and negotiation skills. Domain 1 (Data Gathering) assesses your ability to fully explore the situation before forming a view.

Domain 1 (Primary focus)

Scores well: Clues recognised (hypervigilance, evasiveness, retirement timing). Safe questioning about home. Coercive control screened. Children's safety assessed.

Costs marks: Not exploring home situation. Treating insomnia at face value.

Domain 2 (Primary focus)

Scores well: Not prescribing benzodiazepines. Safe follow-up arranged. Helpline provided if disclosed. Door left open if not. Children's safety considered.

Costs marks: Prescribing benzodiazepines. No follow-up. Not considering safety.

Domain 3 (Primary focus)

Scores well: Creating safe space. Not forcing disclosure. Validating if she discloses. Leaving the door open. Sensitive questioning.

Costs marks: Forcing disclosure. Being judgmental. Closing the door. Insensitive questioning.

Common examiner feedback (and how to fix it)

Did not demonstrate adequate ethical reasoning or application of relevant guidelines

Fix: Structure your response around the four ethical pillars (autonomy, beneficence, non-maleficence, justice). Reference specific guidelines (GMC, Mental Capacity Act) where relevant.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Acknowledge the emotional weight of the situation early. Show that you understand why this is difficult before applying ethical reasoning.

Common mistakes in this station

  1. Treating insomnia at face value without exploring the home situation
  2. Prescribing benzodiazepines: sedation in a woman who needs to be alert to danger is harmful
  3. Forcing disclosure: if she is not ready to tell you, pressuring will close the door

Resitting PLAB 2?

If you have found ethics stations difficult, focus on learning a clear ethical framework (the four pillars) and practising how to apply it conversationally rather than reciting principles. Examiners reward candidates who can explore the tension between competing ethical principles while remaining empathic and non-judgmental.

Example opening

Thank you for coming in to speak with me. My name is Dr [Name]. I understand there is something important we need to discuss. Could you tell me your understanding of the situation?

Frequently asked questions

What is the right way to handle the insomnia (Domestic abuse) scenario in this station?

Domestic violence often presents as a different complaint (insomnia, headache, depression). The candidate must recognise the clues and create space for disclosure. Mrs Yeoh is 42, presenting with insomnia.

Where are marks won and lost in this insomnia (Domestic abuse) station?

Examiners reward: Clues recognised (hypervigilance, evasiveness, retirement timing). Safe questioning about home. Coercive control screened. Children's safety assessed. Candidates are penalised for: Not exploring home situation. Treating insomnia at face value.

Where do candidates most often go wrong in this station?

Treating insomnia at face value without exploring the home situation. Another frequent error: Prescribing benzodiazepines: sedation in a woman who needs to be alert to danger is harmful.

Can I do well in this station without real-world experience of insomnia (Domestic abuse)?

This station rewards process over personal experience. The skill being assessed: Retirement as a risk factor: sudden increased proximity and loss of the victim's safe time alone. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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