Anxiety OSCE - Generalised Anxiety Disorder

Case Overview

• Age/Sex: 33-year-old female
• Occupation: Office administrator
• Setting: Primary care / outpatient clinic
• Chief complaint: "Feeling anxious and on edge"

Patient Script

Who I Am

I'm 33, I work full-time in an office doing administrative work, and I've been feeling under a lot of pressure lately.

What Brings Me In

I've been feeling anxious and on edge most days for months and it's starting to affect my sleep and work.

My Story

For about 8 months I've been worrying a lot about everyday things — my work, whether I'm doing a good job, bills, and little things at home. The worry is present most days and feels difficult to stop. Over the last 3 months it's got worse: I'm tired all the time, have trouble falling asleep and I wake early, feel restless, and my muscles are often tight, especially in my neck and shoulders. I also find it hard to concentrate at work and get easily irritated by colleagues.

Sometimes I get a bit of a racing heart when I'm stressed or after lots of coffee, but I don't have sudden severe panic attacks. A few months ago I increased my coffee from about 2 cups to 4–5 cups a day because my job got busier — that seemed to make my jitteriness worse at first. I was promoted 3 months ago and the new role has more responsibility, which probably hasn't helped. I haven't been suicidal, but this constant worrying is making me consider whether I should see someone about it.

My Medical Background

• Past medical history: no chronic medical conditions, childhood asthma (rare wheeze)
• Medications: combined oral contraceptive pill, occasional ibuprofen for headaches
• Allergies: none known
• Social: lives alone, works full-time, drinks socially (~1–2 units/week), non-smoker, denies recreational drugs
• Caffeine: increased to 4–5 cups/day in last 2–3 months (recent change)
• Family history: mother has had episodes of anxiety/panic in the past

What I Think & Worry About

• I feel like I'm not coping: I worry that I'm just burnt out or weak and should be able to manage this myself.
• I'm worried I might be developing something more serious, like a heart problem because of the palpitations.
• I would like help that actually makes me feel calmer and helps me sleep better so I can do my job properly.

If You Ask Me About Other Symptoms...

• Chest pain: I get occasional mild tightness when very stressed, but no severe chest pain.
• Palpitations: sometimes after lots of coffee or when anxious, but they come and go.
• Panic attacks: I haven't had sudden overwhelming terror or derealisation episodes like in a panic disorder.
• Mood: I feel low at times because I'm tired, but I don't feel hopeless or think about harming myself.
• Sleep: trouble falling asleep, wake early, feel unrefreshed in the morning.
• Weight/appetite: stable appetite and weight over the last year.
• Menstrual: periods regular; on OCP.
• Energy: often fatigued despite no change in activity.
• Other: occasional tension headache, no dizzy spells, no breathlessness at rest.

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Clinical Summary

Examination

• General: alert, cooperative, appears mildly anxious and restless; fidgety in chair
• Vitals: HR 88 bpm, BP 118/76 mmHg, RR 14/min, Temp 36.7°C, SpO2 99% on air
• Cardiovascular: normal S1/S2, no murmurs, no peripheral oedema
• Respiratory: clear bilateral breath sounds
• Abdominal: soft, non-tender
• Neurological: no focal deficits; normal coordination
• Thyroid/neck: no palpable goitre
• Musculoskeletal: mild tenderness/stiffness in trapezius muscles

Investigations

• Full blood count: Hb 13.6 g/dL, WCC 6.4 x10^9/L, platelets 260 x10^9/L (no anaemia)
• TSH: 2.1 mIU/L (within reference range; makes hyperthyroidism unlikely)
• ECG: sinus rhythm, rate 86 bpm, no ischaemic changes or arrhythmia
• Urine pregnancy test: negative
• Urine drug screen: negative
• Fasting glucose: 5.2 mmol/L (normal)
• CRP: <5 mg/L (normal) (Interpretation: no biochemical explanation found for anxiety symptoms; cardiac and thyroid causes unlikely based on tests.)

Diagnosis

Primary diagnosis:

• Generalised Anxiety Disorder (GAD)
  • Evidence: excessive worry present most days for ~8 months, difficulty controlling worry, associated symptoms including restlessness, fatigue, difficulty concentrating, muscle tension, sleep disturbance and irritability; functional impairment at work.

Differential diagnoses (with reasoning):

• Panic disorder: less likely — no recurrent unexpected discrete panic attacks or recurrent periods of intense fear with autonomic symptoms as the predominant feature.
• Hyperthyroidism: unlikely — TSH normal, no goitre or sustained tachycardia.
• Caffeine-induced anxiety: contributory factor (recent increase in intake) but caffeine increase is recent and does not fully explain the duration and breadth of symptoms.
• Major depressive disorder: possible comorbidity, but patient does not report persistent low mood or anhedonia as the predominant issue.
• Substance-induced or medication-related anxiety: unlikely given negative drug screen and medication list.

Management

• Immediate/safety: assess risk (patient denies suicidal ideation); provide supportive listening and safety-netting instructions, advise to seek urgent help if suicidal thoughts develop.
• Psychoeducation: explain GAD diagnosis, chronic course, common physical symptoms, and role of stress/caffeine.
• Lifestyle measures: reduce caffeine intake, improve sleep hygiene, regular physical activity, relaxation/breathing exercises, limit alcohol.
• Psychological therapy: refer for cognitive behavioural therapy (CBT) or guided self-help as first-line treatment; consider waiting lists and local IAPT/mental health services.
• Pharmacotherapy: discuss initiation of an SSRI (e.g., sertraline) if symptoms are moderate-severe or if CBT alone is insufficient; start at low dose and review after 2–4 weeks for side effects and response.
• Short-term symptomatic relief: consider short course of benzodiazepine only for severe acute anxiety while waiting for therapy, but avoid routine use because of dependence risk; discuss risks/benefits.
• Workplace: discuss possible temporary adjustments and referral to occupational health if needed.
• Follow-up: arrange review in 2–4 weeks to assess response to initial measures, medication decision, and safety; monitor for development of depressive symptoms or worsening anxiety.

Key Learning Points

• GAD is characterised by excessive worry occurring more days than not for at least 6 months, with associated somatic and cognitive symptoms (restlessness, fatigue, muscle tension, sleep disturbance, poor concentration).
• Always exclude medical and substance causes (thyroid disease, stimulants, intoxication/withdrawal, cardiac causes) before attributing symptoms to a primary anxiety disorder.
• First-line treatments include CBT and SSRIs; benzodiazepines may be used short-term for severe distress but carry dependence risks and should not be a long-term solution.