Anxiety History Taking – OSCE Guide

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Taking an anxiety history is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking an anxiety history in an OSCE setting.


Tips

Some general tips when taking a history of anxiety:

  • Allow lots of gaps to allow the patient to speak freely and use the space in the way they choose
  • Use active listening skills like head nodding and open posture to show the patient that you are engaged in conversation even when you’re not speaking
  • Talking about mental health problems can be upsetting for patients, so make sure you have some tissues ready and give the patient space to express their emotions as needed
You might also be interested in our premium collection of 1,000+ ready-made OSCE Stations, including a range of communication skills and history taking stations ✨

What is anxiety?

Anxiety is defined as “a feeling of unease, such as worry or fear, that can be mild or severe”. While everyone will feel anxious occasionally, it becomes a medical issue when these feelings are constant, uncontrollable and/or impacting daily life.

There are several types of anxiety disorders, including generalised anxiety disorder (GAD), phobic anxiety disorders, and panic disorder. For more information, see the Geeky Medics guide to anxiety disorders.


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient, including your name and role.

Confirm the patient’s name and date of birth.

Ask the patient if they’d be happy to talk with you about their current issues.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

  • Demonstrating empathy in response to patient cues: both verbal and non-verbal.
  • Active listening: through body language and your verbal responses to what the patient has said.
  • An appropriate level of eye contact throughout the consultation.
  • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
  • Making sure not to interrupt the patient throughout the consultation.
  • Establishing rapport (e.g. asking the patient how they are and offering them a seat).
  • Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
  • Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

  • “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.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

  • “Ok, can you tell me more about that?”
Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.


Exploring symptoms of anxiety

Often, patients will refer to experiencing anxiety as “attacks” of symptoms. However, different patients may use different terms.

Tip: By using the language that the patient uses, you demonstrate that you’re listening to what they’re saying and can also put them at ease. Try to listen to what specific words the patient uses and use the same language where possible.

Symptoms often include a combination of psychological and physical symptoms.

Psychological symptoms

Psychological symptoms of anxiety include:

  • Feeling nervous or restless/tired or fatigued
  • Sense of impending doom
  • Difficulty thinking about anything other than fear or worry
  • Feeling to urgent need to leave a situation
  • Low sense of self-worth

“How does it feel when you have an attack?”

Physical symptoms

Physical symptoms of anxiety include:

  • Feeling very hot and sweating/very cold and shivering
  • Hyperventilation
  • Rapid heart rate or palpitations
  • Headache
  • Nausea
  • Shortness of breath
  • Pins and needles

“When you feel anxious, how does your body feel?”

If the patient is struggling to put into words how they feel when they feel anxious, you can help by asking about the specific symptoms listed above:

  • “Do you notice a change in your breathing when you feel anxious?”
  • “Do you notice any changes in temperature?”

When asking questions about specific symptoms, avoid using leading questions, as this may alter the patient’s response. The patient may feel inclined to say yes if they feel certain symptoms are required to receive help (e.g. “do you feel sick?”)

Timing of symptoms

Depending on the underlying cause of anxiety, symptoms may be triggered by specific situations, come on randomly throughout the day, or they may be constant.

Determining when the symptoms occur can help you make the eventual diagnosis. For example, social anxiety brings about symptoms in social situations or when thinking about social situations. In contrast, generalised anxiety disorder (GAD) tends to be more constant and without a clear pattern.

Again, try to use open questions where possible:

  • “Can you describe a pattern of when you get these symptoms?”
  • “Is there anything in particular that brings on an attack?”
  • “When you notice you start feeling anxious, is it usually when you’re doing a particular activity?”

Relieving factors

For some people with anxiety, certain things can help settle their symptoms, while for others, nothing they do seems to help.

This, again, can help us determine the type of anxiety disorder they are experiencing. For example, patients with agoraphobia (anxiety as a result of leaving the house or crowds or public places) will often find their anxiety settles once their back in their house. In contrast, patients with GAD will often say that nothing they do will stop the anxiety.

  • “Is there anything you’ve found settles the anxiety?”
  • “What do you do, if anything, to try and stop an attack?”

Assess suicide risk

Anxiety disorders often co-exist with depression, and it is important to assess the risk of suicide. Many healthcare professionals feel uncomfortable asking questions to determine suicide risk. However, by sensitively asking about suicidal ideation, you are safeguarding the patient. It can help to know that asking about suicidal ideation does not increase the risk of your patient acting on any thoughts.

Questions that can be useful to determine a patient’s risk of suicide include:

  • “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?”

See our suicide risk assessment guide for more details.


Screening for other psychiatric diagnoses

While anxiety can be a disorder in itself, it can also be a symptom of another underlying psychiatric condition. Anxiety is also strongly associated with depression, and the two can co-exist. As a result, it’s important to ask questions relating to general psychiatric health such as: 

  • “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?”

For more information, see the Geeky Medics guide to taking a psychiatric history.

Screening for depression

NICE guidelines recommend the questions below to briefly screen for depression.

“During the past month have you…”

  • “Felt low, depressed or hopeless?”
  • “Had little interest or pleasure in doing things?”

For more information, see the Geeky Medics guide to depression history taking.


Past psychiatric history

Previous episodes of 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 history:

  • “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

Ask if the patient has any medical conditions: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”

Some medical conditions can cause symptoms of anxiety (organic causes):

  • Hyperthyroidism
  • Pheochromocytoma 
  • Hypoparathyroidism
  • Angina 
  • Arrhythmias

Understanding your patient’s medical history can also help you understand them as a whole and formulate an appropriate treatment plan that considers their co-morbidities. For example, a patient with asthma would usually not be prescribed beta-blockers.

Chronic illness is also a major risk factor for anxiety disorders (e.g. chronic pain, cancer, etc).

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).


Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication namedosefrequencyform and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”
Examples of relevant medications

There are links between anxiety and certain prescription medications. Medications which can cause or worsen anxiety include:

  • Corticosteroids
  • Levothyroxine
  • Methylphenidate
  • Pseudoephedrine (found in decongestants)

While many people diagnosed with anxiety have no apparent cause, it’s important to assess whether medications or other substances can be causative. If a possible pharmacological cause is found, it may be appropriate to suggest changes to medication.


Family history

Ask the patient if there is any family history of psychiatric disease in first-degree relatives:

  • “Have any of your parents or siblings had problems with their mental health?”
  • “Do you know what type of mental health problems they had?”

Anxiety disorders can have a genetic component, and a strong family history of anxiety disorders or other psychiatric disorders can further support a diagnosis of an anxiety disorder. However, this is not required for diagnosis.


Social history

Explore the patient’s social history to understand their social context and identify potential psychiatric risk factors.

General social context

Explore the patient’s general social context including:

  • the type of accommodation they currently reside in (e.g. house, bungalow) and if they have any adaptations to assist them (e.g. stairlift)
  • who the patient lives with and their personal support network
  • what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)

Assess the impact of patient’s anxiety symptoms on their relationships and work:

  • “Has your anxiety affected your friendships?”
  • “Are you able to socialise regularly with others?”
  • “Are you in a relationship at the moment? How has this been affected?”
  • “Have you told any friends/family/anyone how you are feeling?”
  • “Has your anxiety affected your ability to work?”
  • “Are you able to concentrate on tasks at work?”
  • “Has your mood caused you to take any time off work?

Asking your patient about their day-to-day life is essential in any psychiatric history as it helps you to understand how the patient is coping and can indicate the severity of their condition and whether they require urgent intervention.

Sleep

Patients with anxiety disorders often have disrupted sleep, either insomnia or sleeping too much:

  • “How are you sleeping?”
  • “Do you find you wake up during the night?”
  • “Do you struggle to fall asleep?”
  • “Do you feel tired during the daytime?”

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Alcohol

Record the frequencytype and volume of alcohol consumed on a weekly basis.

See our alcohol history taking guide for more information.

Recreational drug use

Ask the patient if they use recreational drugs, and if so, determine the type of drugs used and their frequency of use. 

The effects of drugs and alcohol can temporarily mask the symptoms of anxiety. It’s not uncommon to find alcohol/substance misuse in patients with anxiety disorders. 

If a patient discloses harmful drug or alcohol use during a history taking, it’s essential to signpost them to appropriate services. 

Gambling

Ask the patient if they gamble and if they feel this is a problem.

Gambling addiction is also more prevalent in patients with anxiety disorders, and can not only worsen symptoms but can cause significant financial problems, problems with sleep, reduced levels of self-care and sedentary behaviour. Those with gambling addiction are more at risk of substance misuse.

Problematic gambling can be assessed via the Problem Gambling Severity Index (PGSI).


Closing the consultation

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


Reviewer

Dr Cynthia Gil-Rios

Consultant psychiatrist


 

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