Anxiety History Taking – OSCE Guide

Introduction

Taking an anxiety history is a crucial skill often assessed in Objective Structured Clinical Examinations (OSCEs).
This guide offers a structured approach to facilitating an anxiety history in an OSCE environment.
Related resources include:
- Anxiety history taking PDF OSCE checklist.
- Interactive OSCE checklist.
- Mental state examination (MSE) guide.
- Depression history-taking guides.

General Tips for History Taking

Allow ample silence for the patient to express themselves freely, creating a comfortable atmosphere.
Employ active listening skills through non-verbal cues such as head nodding and maintaining an open posture to convey engagement during the consultation.
Prepare for emotional discussions; have tissues available and provide the patient with space to express emotions as needed.

Understanding Anxiety

Definition of Anxiety

Anxiety is defined as "a feeling of unease, such as worry or fear, that can be mild or severe".
Normal versus pathological anxiety:
- It becomes a medical concern when feelings are:
- Constant,
- Uncontrollable,
- Impacting daily life.
Types of anxiety disorders include:
- Generalised anxiety disorder (GAD),
- Phobic anxiety disorders,
- Panic disorder.

Opening the Consultation

Wash hands and don personal protective equipment (PPE) if appropriate.
Introduce yourself (name and role).
Confirm the patient’s name and date of birth.
Ask for the patient’s consent to discuss their issues.

General Communication Skills

Maintain a patient-centered approach by integrating general communication skills, which include:
- Demonstrating empathy through verbal and non-verbal responses.
- Active listening via body language and verbal feedback.
- Maintaining appropriate eye contact throughout.
- Using open, relaxed, and professional body language (e.g., uncrossed limbs).
- Avoiding interruptions during the consultation.
- Establishing rapport by inquiring about the patient’s well-being and inviting them to sit.
- Signposting the discussion - indicating what has been discussed and what will be addressed next.
- Summarising regularly to recap key points.
- Utilizing open questions to explore the patient’s presenting complaint.

Exploring Symptoms of Anxiety

Psychological Symptoms

Initiate with open-ended questions, such as:
- “How are you today?”
- “How have you been feeling recently?”
- “What’s brought you in to see me today?”
- “Tell me about the issues you’ve been experiencing.”
Allow sufficient time for responses; avoid interruptions.
Encourage expansion on presenting complaints with questions like “Can you tell me more about that?”

Open vs Closed Questions

Use a combination of:
- Open questions at the beginning, which allow free expression of thoughts.
- Closed questions to delve deeper into specific symptoms and risk factors.
Encourage patients to use their own language to describe their symptoms to enhance comfort and rapport.

Symptoms of Anxiety

Common psychological symptoms include:
- Nervousness or restlessness.
- Fatigue or tiredness.
- Sense of impending doom.
- Difficulty focusing on anything other than fear or worry.
- Urgency to leave situations.
- Low self-worth.
Examples of questions to assess psychological experiences:
- “How does it feel when you have an attack?”

Physical Symptoms

Typical physical symptoms include:
- Sweating or shivering.
- Hyperventilation.
- Rapid heart rate or palpitations.
- Headaches.
- Nausea.
- Shortness of breath.
- Pins and needles sensation.
Inquiry on physical symptoms can include:
- “When you feel anxious, how does your body feel?”
- Specific symptom prompts to aid patient expression without leading responses.

Timing of Symptoms

Identifying the pattern of symptom occurrence:
- Symptoms may appear in specific situations (e.g., social anxiety) or could be constant (e.g., GAD).
Example questions:
- “Can you describe a pattern of when you get these symptoms?”
- “Is there anything in particular that brings on an attack?”

Relieving Factors

Explore what helps alleviate symptoms:
- “Is there anything you’ve found settles the anxiety?”
- “What do you do, if anything, to try and stop an attack?”

Assessing Suicide Risk

Importance of assessing for suicidal ideation due to potential co-occurrence of anxiety and depression.
Examples of sensitive questions to assess risk:
- “Have you ever had thoughts about harming yourself?”
- “Do you ever have thoughts about ending your own life?”
- “Have you ever acted on thoughts to end your life or harm yourself?”
- “Is there anything stopping you from acting on these thoughts?”
- “Who might you talk to if you were having thoughts to end your life?”
Making these inquiries sensitively is key to safeguarding patients.

Screening for Other Psychiatric Diagnoses

Anxiety may represent a symptom of other underlying psychiatric issues.
Questions relating to general mental health include:
- “How is your mood?”
- “In the last few months, have you found yourself feeling low?”
- “Do you feel your thoughts are your own?”
- “Do you ever hear or see things that others may not be able to?”

Screening for Depression

NICE guidelines recommend asking about:
- “During the past month have you…”
- “Felt low, depressed, or hopeless?”
- “Had little interest or pleasure in doing things?”

Past History

Past Psychiatric History

Previous experiences related to anxiety:
- “Have you ever had any other periods of feeling particularly anxious?”
- “Have you ever received any treatment(s) for anxiety in the past, and if so, did they help?”
General psychiatric background queries:
- “Have you previously had any problems with your mental health?”
- “Have you ever been diagnosed with a psychiatric condition?”
- “What treatment(s) did you receive for this diagnosis, and did they seem to help?”
- “Have you ever been admitted to the hospital because of your mental health?”

Past Medical History

Explore the patient’s medical conditions that could relate to anxiety:
- Medical conditions that might manifest symptoms of anxiety (organic causes):
- Hyperthyroidism,
- Pheochromocytoma,
- Hypoparathyroidism,
- Angina,
- Arrhythmias.
Formulate a treatment plan aligning with the patient’s medical history.

Allergies and Drug History

Discuss any allergies:
- Obtain details on the type and severity of reactions (mild rash vs anaphylaxis).
Medications:
- “Are you currently taking any prescribed medications or over-the-counter treatments?”
- Document details about medications: name, dose, frequency, form, and route.
- Inquire about side effects: “Have you noticed any side effects from the medication you currently take?”

Relevant Medications Causing Anxiety

Some medications can induce or exacerbate anxiety:
- Corticosteroids,
- Levothyroxine,
- Methylphenidate,
- Pseudoephedrine.

Family History

Investigate family history of psychiatric disorders:
- “Have any of your parents or siblings had problems with their mental health?”
- “Do you know what type of mental health problems they had?”
Consider genetic factors in diagnosing anxiety disorders; however, such a history is not essential.

Social History

General Social Context

Contextualize the patient’s living situation:
- Type of accommodation,
- Support network,
- Independence versus need for assistance.
Examine impacts of anxiety on social relationships and work life:
- “Has your anxiety affected your friendships?”
- “Are you able to socialise regularly with others?”
- “Have you told any friends/family how you are feeling?”
- “Has your anxiety affected your ability to work?”

Impact on Sleep, Smoking, and Alcohol

Understand how anxiety influences daily living:
- Sleep disturbances:
- “How are you sleeping?”
- “Do you find you wake up during the night?”
- Smoking history and habits.
- Alcohol consumption: frequency, type, and volume on a weekly basis.

Recreational Drug Use and Gambling

Inquiry on recreational drug use:
- Determine type and frequency of use.
Assess for gambling behaviors:
- “Do you gamble, and feel it could be a problem?”
- Recognize the overlap between gambling addiction and anxiety disorders, and its broader implications (financial issues, sleep disturbances, etc.).

Closing the Consultation

Address any remaining questions or concerns the patient has not mentioned.
Thank the patient for their time and cooperation.
Dispose of PPE properly and wash hands appropriately.

Overview of Anxiety History Taking

Definition: Pathological anxiety is defined as worry or fear that is constant, uncontrollable, and impacts daily life, differentiating it from normal stress.
Preparation: Ensure a patient-centered environment by utilizing active listening, providing tissues for emotional distress, and signposting the consultation stages.

Clinical Assessment

Inquiry: Start with open-ended questions ( $e.g.$ , "How have you been feeling?") before moving to specific closed questions to identify patterns.
Symptoms:
- Psychological: Nervousness, fatigue, sense of impending doom, and low self-worth.
- Physical: Palpitations, hyperventilation, sweating, nausea, and pins and needles.
Timing: Determine if symptoms are situational ( $e.g.$ , Social Anxiety) or constant ( $e.g.$ , GAD).

Safety and Comorbidities

Suicide Risk: Always screen for suicidal ideation or intent due to the high co-occurrence of depression and anxiety.
Psychiatric Screening: Rule out depression using NICE guidelines (assessing low mood and anhedonia) and screens for psychosis.

Historical Context

Medical History: Screen for organic causes such as hyperthyroidism, arrhythmias, or pheochromocytoma.
Drug History: Identify medications that may mimic anxiety, such as corticosteroids, levothyroxine, or stimulants.
Social History: Assess the impact on employment, relationships, sleep, and the use of alcohol, smoking, or recreational drugs (especially gambling).