History Taking · Advanced · Psychiatry

Persistent Worry and Physical Tension

Practise this PLAB 2 history taking station on Generalised Anxiety Disorder. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in primary care. Pankaj Bhattacharya, a 42-year-old man, has come to see you with a persistent sense of worry and physical tension. He describes feeling on edge most of the time and experiencing muscle tension, particularly in his neck and shoulders. Please take a focused history and discuss assessment and management options for his anxiety symptoms.

Background notes: PMH: Occasional tension headaches

What this station tests

  • GAD-7 framework: excessive worry about multiple topics for >6 months with physical symptoms
  • Anxiety-physical symptom link: explaining that palpitations and chest tightness are stress response, not cardiac
  • SSRI initial worsening: anxiety can worsen in first 1-2 weeks, start low and titrate slowly
  • CBT as first-line psychological treatment for GAD per NICE
  • Excluding hyperthyroidism: TFTs to rule out thyroid as a mimic of anxiety

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

GAD presents with persistent worry plus physical symptoms that patients often attribute to physical illness. The candidate must validate the physical symptoms while identifying the anxiety pattern. Mr Bhattacharya is 42, a senior accountant, with persistent worry and physical tension. He thinks he has a heart problem. Open with: 'Mr Bhattacharya, tell me about the symptoms and what concerns you most.'

Core approach

Identify the GAD pattern (GAD-7 framework). Excessive, uncontrollable worry about multiple topics (work, finances, children's safety, health) for at least 6 months. Associated physical symptoms: muscle tension (neck, shoulders, jaw clenching), fatigue, poor concentration, irritability, sleep disturbance (difficulty falling asleep due to racing thoughts), restlessness.

His physical symptoms (palpitations, chest tightness, dizziness) have led him to believe he has cardiac disease. Explain the anxiety-physical symptom link: 'Anxiety produces real physical symptoms. The palpitations and chest tightness are caused by your body's stress response, not by heart disease.'

Exclude physical causes: check TFTs (hyperthyroidism mimics anxiety), FBC, glucose. ECG if cardiac symptoms are prominent (reassures and excludes). Caffeine intake (exacerbates anxiety). Alcohol use (self-medication).

Closing and safety netting

Treatment per NICE stepped care. Mild: guided self-help, psychoeducation, exercise (evidence-based for anxiety). Moderate: CBT (first-line psychological treatment for GAD) or SSRI (sertraline or escitalopram). He may prefer trying CBT before medication. If SSRI started: warn about initial anxiety worsening in first 1 to 2 weeks (start low, titrate slowly).

Practical strategies: reduce caffeine, regular exercise (30 minutes 5 times weekly), sleep hygiene, mindfulness or relaxation techniques. Reassure: 'GAD is very common and very treatable. Most people improve significantly with the right approach.' Safety net: if anxiety becomes overwhelming or he develops suicidal thoughts, come back urgently. Follow-up in 4 weeks.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for generalised anxiety disorder. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: GAD-7 applied. Physical causes excluded (TFTs, ECG). Caffeine and alcohol assessed. Duration and functional impact documented.

Costs marks: Not excluding physical causes. Not assessing duration. No caffeine/alcohol check.

Domain 2 (Primary focus)

Scores well: Stepped care applied. CBT offered. SSRI with initial worsening warning. Practical strategies. Exercise recommended.

Costs marks: No CBT. No SSRI warning. No practical strategies.

Domain 3 (Throughout)

Scores well: Validating physical symptoms as real. Explaining the mechanism (stress response). Not dismissing. Providing hope about treatability.

Costs marks: Dismissing as 'just anxiety.' Not explaining the mechanism. Being purely pharmacological.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Dismissing physical symptoms as 'just anxiety': the symptoms are real, caused by the stress response
  2. Not checking TFTs: hyperthyroidism mimics GAD perfectly
  3. Not warning about SSRI initial worsening: patients may stop the medication thinking it is making them worse

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this generalised anxiety disorder station?

GAD presents with persistent worry plus physical symptoms that patients often attribute to physical illness. The candidate must validate the physical symptoms while identifying the anxiety pattern. Mr Bhattacharya is 42, a senior accountant, with persistent worry and physical tension.

What does a strong performance look like to the examiner in this station?

Strong performances show: GAD-7 applied. Physical causes excluded (TFTs, ECG). Caffeine and alcohol assessed. Duration and functional impact documented. Weak performances: Not excluding physical causes. Not assessing duration. No caffeine/alcohol check.

What is the biggest pitfall in this generalised anxiety disorder station?

Dismissing physical symptoms as 'just anxiety': the symptoms are real, caused by the stress response.

How should I prepare for generalised anxiety disorder if I have never seen it in practice?

Structure beats experience here. Focus on anxiety-physical symptom link: explaining that palpitations and chest tightness are stress response, not cardiac. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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