Anxiety OSCE - Health Anxiety

Case Overview

• Age/Sex: 42-year-old female
• Occupation: Office worker (administrative assistant)
• Setting: Primary care / GP clinic
• Chief complaint: "I've been feeling anxious and on edge — I'm worried something is seriously wrong with me."

Patient Script

Who I Am

I'm a 42-year-old office worker, married, mum of two, and I work full time doing admin for a local company.

What Brings Me In

I've been feeling constantly anxious about my health for months and I keep thinking I have something seriously wrong, so I thought I should see someone about it.

My Story

It started about 6 months ago after a colleague had a long illness and I began worrying that I might have something similar. Over the last 2 months the worry has become much worse — I'm constantly thinking I have a serious disease, especially cancer or a heart problem. I check my body a lot, like my pulse and lumps, and I spend hours on health websites. I have seen my GP three times and had blood tests and an ECG about 4 weeks ago which she said were fine, but I still worry because the tests might have missed something. I often feel on edge, have trouble sleeping, and find it hard to concentrate at work. I sometimes get a racing heart but that usually happens after too much coffee or when I'm stressed. I know I'm probably overthinking, but I can't stop. I haven't had any major weight loss or fevers. I'm worried this will affect my job and family if it keeps getting worse.

My Medical Background

• Past medical history: mild childhood asthma (rarely symptomatic as an adult), hay fever
• Current medications: salbutamol inhaler PRN, combined oral contraceptive
• Allergies: none known
• Social history: drinks about 6 units alcohol per week, non-smoker (quit 10 years ago), lives with husband and two school-age children
• Family history: mother diagnosed with breast cancer at 62 (now well) — this makes me particularly worried

What I Think & Worry About

• I think I might have a serious illness like cancer or a heart problem that the doctors have missed.
• I'm worried this will get worse and that my family will be left without me or that I won't be able to work.
• I want tests to be absolutely sure and I expect to be examined and possibly sent for more tests to rule things out.

If You Ask Me About Other Symptoms...

• Appetite / weight: "My appetite is okay — I haven't lost weight on purpose."
• Sleep: "I wake several times at night worrying; usually sleep 4–5 hours."
• Energy / mood: "Tired, irritable, a bit low sometimes, but I still manage to do things."
• Chest symptoms: "Occasional palpitations — usually after coffee or when anxious; once had a tight chest when I ran for a bus but it went away."
• Gastrointestinal: "Sometimes some indigestion after big meals, nothing severe."
• Neurology: "Occasional pins-and-needles in my hands if I sleep awkwardly, no weakness or loss of vision."
• Prior investigations: "My GP did blood tests and an ECG a month ago and said they were normal, but I still worry."
• Safety: "I haven't had thoughts of harming myself; I just feel overwhelmed by the worry."

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Clinical Summary

Examination

• General: alert, cooperative woman, mildly anxious but well kempt
• Vitals: BP 118/74 mmHg, HR 82 bpm regular, RR 14/min, Temp 36.7°C, SpO2 98% on air
• BMI: 24 kg/m2
• Cardiovascular: normal S1/S2, no murmurs, no peripheral edema
• Respiratory: clear breath sounds bilaterally, no wheeze at rest
• Abdominal: soft, non-tender, no masses
• Neurological: cranial nerves grossly intact, power and sensation normal, no focal deficit
• Mental state: anxious mood, preoccupation with health, appropriate affect, coherent speech, intact judgment, no psychotic symptoms, no suicidal ideation

Investigations

• CBC: Hb 13.2 g/dL, WBC 6.4 x10^9/L, platelets 250 x10^9/L (within normal limits)
• TSH: 2.1 mIU/L (normal) (rules out hypothyroidism as cause of anxiety)
• CRP: <5 mg/L (normal)
• Random blood glucose: 5.6 mmol/L (normal)
• ECG: sinus rhythm 80 bpm, no ischemic changes (normal)
• Urine pregnancy test: negative (appropriate given age/contraception)

Diagnosis

Primary: Illness anxiety disorder (health anxiety)

• Evidence: >6 months of excessive worry about having a serious illness, persistent preoccupation despite normal investigations and reassurance, repeated checking and internet searching, functional impairment (sleep disturbance, concentration problems at work), reassurance-seeking (multiple GP visits).

Differential diagnoses (with reasoning):

• Generalized anxiety disorder — possible, but the worry is predominantly about health rather than multiple domains.
• Somatic symptom disorder — less likely as there are not prominent or distressing somatic symptoms proportionate to the concern; the main issue is fear of illness rather than severe ongoing physical symptoms.
• Panic disorder — less likely: patient reports occasional palpitations linked to caffeine/anxiety but not discrete recurrent panic attacks with abrupt intense fear and autonomic symptoms.
• Major depressive disorder — mood low at times, but not meeting full criteria for MDD; no anhedonia severe enough to suggest primary depression.
• Cardiac or endocrine pathology — ruled unlikely by history, normal exam, and normal ECG/TSH/bloods; but safety-netting applies.

Management

• Provide empathetic explanation and normalization: acknowledge real distress and explain the diagnosis of health anxiety (illness anxiety disorder).
• Reassurance strategy: explain meaning of normal tests; avoid repeated blanket reassurance as it reinforces checking behaviors.
• Offer psychological therapy: refer for CBT specifically tailored for health anxiety (first-line treatment).
• Consider pharmacotherapy if severe/persistent or CBT not available: start SSRI (e.g., sertraline) after discussing risks/benefits and arrange monitoring.
• Set a clear follow-up plan: arrange GP follow-up in 2–4 weeks to review symptoms and offer coordinated care; agree a plan for limited, targeted investigations if new 'red flag' features arise.
• Practical measures: advise sleep hygiene, relaxation techniques or guided self-help for anxiety, recommend reducing excessive online health searching, and limit symptom-checking behaviours (use behavioural strategies via CBT).
• Safety-netting and liaison: provide safety-netting advice (return earlier for new worrying symptoms like unexplained weight loss, persistent fever, haemoptysis, focal neurological signs); consider brief letter to GP summarizing agreed plan and to discourage unnecessary repeat testing.

Key Learning Points

• Distinguish illness anxiety (health anxiety) from generalized anxiety and somatic symptom disorder: the central feature is persistent fear of having a serious illness despite minimal or no somatic symptoms and repeated reassurance.
• First-line management is psychological (CBT focused on health anxiety); pharmacotherapy (SSRIs) is reserved for moderate–severe cases or when CBT is unavailable.
• Provide structured follow-up and safety-netting rather than repeated ad hoc investigations; indiscriminate testing may reinforce illness beliefs and perpetuate anxiety.