Anxiety OSCE - Social Anxiety

Case Overview

• Age/Sex: 15-year-old female
• Occupation: High-school student (Year 10)
• Setting: Walk-in appointment at adolescent clinic, accompanied by mother who steps out for part of the consultation
• Chief complaint: "Feeling anxious and on edge"

Patient Script

Who I Am

I'm 15, at high school, living with my mum and dad — I mostly keep to myself and try not to cause trouble.

What Brings Me In

I just feel really nervous all the time, especially around other people — it’s getting worse and I’m avoiding things.

My Story

It started about a year ago after I moved up to high school, and the last 6 months it’s been getting worse. I get really scared when I have to speak in class or join a group — my hands shake, I blush, my stomach feels awful and sometimes my heart races. I’ve started sitting at the back of class, pretending to be busy so I don’t get picked, and I always try to avoid presentations. I’ve missed school a few times because I couldn’t face going to an assembly. I’m fine at home with my family but when there are lots of people I feel like everyone is staring at me and thinking I’m weird. I once felt so bad on a crowded bus two months ago that I almost got off early — that was scary, but it hasn’t happened again.

I used to get good grades, but now oral stuff is hard and my teachers think I’m lazy. I don’t like clubs or parties anymore. I don’t drink much, though I sometimes have energy drinks before exams to stay awake. I don’t take any regular medicines.

My Medical Background

• Past medical history: none significant
• Regular medications: none
• Allergies: none known
• Mental health history: I’ve felt anxious before but never like this; no previous therapy
• Family history: Mum has had periods of low mood; an uncle apparently had panic attacks (I’m not sure)
• Social: Lives with both parents, older brother at university, not sexually active, attends school; occasional vaping at parties (rare)

What I Think & Worry About

• I think people must think I’m dumb or weird for being so quiet.
• I’m worried I’ll fail presentations and let my parents down.
• I’m hoping you can help me not feel so nervous and maybe suggest something that won’t make me feel weird or different.

If You Ask Me About Other Symptoms...

• Mood: I feel a bit low sometimes because I’m avoiding everyone, but I haven’t felt like hurting myself.
• Sleep: I have trouble falling asleep most nights because my mind races; I wake up tired.
• Appetite/weight: about the same, no intentional changes.
• Concentration: worse in class, especially around others.
• Physical: I get blushing, trembling, sweaty palms, nausea, and a fast heart sometimes when I’m near people or called on.
• Substance use: I don’t drink regularly, sometimes an energy drink before exams; I tried vaping once or twice with friends.
• Any recent stressors: starting high school, a few awkward incidents in class, and one argument with a close friend a few months ago.
• Past fainting/medical: I fainted once when I was little after getting a shot; nothing recent.

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Clinical Summary

Examination

• General: teenager, appears anxious and guarded, avoids eye contact
• Vitals: HR 96 bpm, BP 110/68 mmHg, RR 16/min, Temp 36.7°C, SpO2 99% on air
• Weight/Height: BMI 21 kg/m2
• HEENT: no goitre, no tremor of lids
• CVS: regular rate, no murmurs
• Respiratory: clear
• Neurological: normal focal exam
• Mental state: coherent speech but quiet, mood described as "a bit down", affect anxious, oriented, intact memory and concentration variable, no psychosis, denies suicidal ideation, insight limited regarding anxiety impact

Investigations

• TSH: 2.0 mIU/L (normal) — no biochemical evidence of hyperthyroidism
• ECG: sinus rhythm, HR ~92 bpm, no conduction abnormalities (normal for age)
• Pregnancy test (urine): negative (not sexually active but checked before considering medication)
• Social Phobia Inventory (SPIN): 35 (scores >19 suggest clinically significant social anxiety; 35 = moderate–severe)
• GAD-7: 10 (moderate generalized anxiety symptoms)
• PHQ-9: 8 (mild–moderate depressive symptoms)

Diagnosis

Primary diagnosis:

• Social anxiety disorder (social phobia)
  • Evidence: fear of negative evaluation in social/performance situations, avoidance of class participation, presentations and social events, physical symptoms (blushing, tremor, palpitations, nausea) in social situations, duration >6 months, and functional impairment (school attendance/grades).

Differential diagnoses:

• Generalized anxiety disorder — considered due to generalized worry, but the anxiety is mainly situation-specific rather than pervasive across many domains.
• Panic disorder — single panic-like episode on bus reported, but lacks recurrent unexpected panic attacks and persistent concern about attacks.
• Major depressive disorder — low mood present but symptoms are better explained as secondary to social avoidance; depression scores are mild–moderate.
• Autism spectrum disorder / social communication difficulties — less likely as patient reports normal interactions at home and specific fear of negative evaluation rather than lack of social interest.

Management

• Immediate: validate concerns, normalize that social anxiety often begins in adolescence and is treatable.
• Psychological: first-line referral to child and adolescent mental health services (CAMHS) or an adolescent psychologist for evidence-based CBT with exposure therapy (individual or group CBT focusing on social skills and graded exposure to feared situations).
• Pharmacological: consider SSRI (e.g., sertraline or fluoxetine) if symptoms are moderate–severe or if CBT insufficient; arrange specialist (CAMHS/paediatrics) involvement prior to starting medication and discuss consent with parents and assent with patient.
• Symptom relief for performance situations: discussion of short-term beta-blocker (e.g., propranolol) for specific performance anxiety may be considered on a case-by-case basis with specialist input and parental consent.
• Practical/school measures: liaison with school for accommodation (e.g., graded exposure for presentations, postponement or smaller group presentations), support from school counselor, gradual re-integration plan, and exam adjustments if needed.
• Lifestyle: advise on reducing energy drinks/caffeine, sleep hygiene, and encouraging low-pressure social activities to build confidence.
• Safety netting: assess and document suicide risk at each contact; provide clear instructions for urgent help if suicidal thoughts or self-harm emerge.
• Follow-up: arrange review in 2–4 weeks after initial assessment or sooner if worsening; monitor response to therapy and for emergence of depressive symptoms.

Key Learning Points

• Social anxiety disorder often begins in adolescence and is characterized by persistent fear of negative evaluation, avoidance of social/performance situations, and physical anxiety symptoms; duration >6 months with functional impairment supports the diagnosis.
• First-line treatment in adolescents is evidence-based CBT with graded exposure; SSRIs are reserved for moderate–severe cases or when psychotherapy alone is insufficient and should involve specialist input.
• Always consider and rule out medical mimics (thyroid disease, stimulants/caffeine, substance use) and assess for comorbid conditions (depression, panic disorder); liaise with family and school to support functional recovery.