Case Information
- Case ID: ANX-008
- Patient Name: Rachel Turner
- Age: 32
- Gender: Female
- Indigenous Status: Non-Indigenous
- Year: 2025
- ICPC-2 Codes: P74 – Anxiety Disorder/Anxiety State
Competency Outcomes
| Competency Domain | Competency Element |
|---|---|
| 1. Communication and Consultation Skills | Establishing rapport, validating patient concerns, and exploring psychosocial factors contributing to anxiety |
| 2. Clinical Information Gathering and Interpretation | Taking a structured history to assess symptom severity, triggers, and ruling out medical causes of anxiety |
| 3. Diagnosis, Decision-Making and Reasoning | Identifying generalised anxiety disorder (GAD) based on DSM-5 criteria and distinguishing from other psychiatric and medical conditions |
| 4. Clinical Management and Therapeutic Reasoning | Developing an evidence-based management plan including psychological, pharmacological, and lifestyle interventions |
| 5. Preventive and Population Health | Discussing stress management techniques, lifestyle modifications, and early intervention strategies |
| 6. Professionalism | Providing patient-centred care, ensuring confidentiality, and supporting shared decision-making |
| 7. General Practice Systems and Regulatory Requirements | Ensuring appropriate referral to mental health services and documentation for Medicare Mental Health Treatment Plans |
| 9. Managing Uncertainty | Addressing concerns about medication use, side effects, and the chronic nature of anxiety |
| 10. Identifying and Managing the Patient with Significant Illness | Recognising when specialist psychiatric input is required (e.g., suicidality, severe functional impairment) |
Case Features
- 32-year-old female marketing executive presenting with persistent worry, restlessness, and difficulty sleeping for the past six months.
- Reports excessive worrying about work, finances, and relationships, struggling to “switch off”.
- Physical symptoms include muscle tension, headaches, and a feeling of being “on edge”.
- No history of panic attacks, but occasionally feels breathless when stressed.
- No prior mental health diagnoses, denies suicidal ideation, and has never taken psychotropic medication.
- Has increased alcohol intake (3-4 drinks per night) as a coping mechanism.
- Concerned about losing control and wants to discuss treatment options.
Candidate Information
Instructions
The candidate is expected to review the following patient record and scenario. The examiner will ask a series of questions based on this information. The candidate has 15 minutes to complete this case.
The approximate time allocation for each question:
- Question 1: 3 minutes
- Question 2: 3 minutes
- Question 3: 3 minutes
- Question 4: 3 minutes
- Question 5: 3 minutes
Patient Record Summary
Patient Details
- Name: Rachel Turner
- Age: 32
- Gender: Female
- Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- No known drug allergies
Medications
- Nil regular medications
Past History
- No history of depression, anxiety, or other mental health conditions
Social History
- Works in a high-pressure marketing role, long hours and tight deadlines
- Lives with her partner, no children
- Increased alcohol intake (3-4 drinks per night to “calm down”)
- No illicit drug use, non-smoker
Family History
- Mother has depression, managed with antidepressants
- No family history of anxiety disorders
Vaccination and Preventive Activities
- Influenza vaccine: Up to date
- COVID-19 booster: Received
Scenario
Rachel Turner, a 32-year-old marketing executive, presents with persistent anxiety symptoms lasting six months, including excessive worry, muscle tension, and sleep disturbances.
She describes constant rumination about work and personal responsibilities, which interferes with concentration and relaxation. She has started drinking 3-4 alcoholic drinks each evening to cope.
Rachel has never had a mental health diagnosis or taken medication for anxiety, and she denies suicidal ideation. She is concerned about her ability to manage stress long-term and wants to discuss treatment options.
On examination:
- Mental State Exam:
- Mood: Anxious, mildly tense
- Affect: Worried, engaged
- Thought process: Logical, excessive preoccupation with daily concerns
- Cognition: No impairment
- Suicidal ideation: Denied
Likely Diagnosis: Generalised Anxiety Disorder (GAD)
Examiner Only Information
Questions
Q1. How would you assess whether Rachel’s symptoms meet the criteria for generalised anxiety disorder?
- Prompt: What key features in her history support a diagnosis of GAD?
- Prompt: What medical conditions should be ruled out?
Q2. What treatment options would you discuss with Rachel?
- Prompt: What are the first-line non-pharmacological and pharmacological treatments?
- Prompt: How would you address her concerns about medication?
Q3. How would you approach Rachel’s alcohol use in the context of anxiety?
- Prompt: What are the risks of using alcohol as a coping strategy?
- Prompt: How would you provide brief intervention counselling?
Q4. How would you develop a mental health treatment plan for Rachel?
- Prompt: What are the key components of a GP Mental Health Treatment Plan (MHTP)?
- Prompt: What referrals or services should be considered?
Q5. When would you consider specialist referral for Rachel?
- Prompt: What are the indications for referral to a psychiatrist or psychologist?
- Prompt: How would you assess for worsening symptoms requiring urgent review?
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Q1: How would you assess and confirm a diagnosis of generalised anxiety disorder (GAD)?
The competent candidate should:
- Establish key diagnostic features:
- Persistent and excessive worry about multiple aspects of life (work, finances, relationships).
- Symptoms present for ≥6 months.
- Physical symptoms: Fatigue, muscle tension, restlessness, difficulty sleeping, and impaired concentration.
- Differentiate from other conditions:
- Other anxiety disorders (e.g., panic disorder, social anxiety, phobias).
- Depression (assess mood, anhedonia, suicidal ideation).
- Medical causes: Hyperthyroidism, cardiac conditions, medication side effects.
- Use validated screening tools:
- GAD-7 to assess symptom severity.
- Consider DASS-21 for broader psychological distress screening.
Q2: What are the initial management strategies for Sarah’s anxiety?
The competent candidate should:
- Non-pharmacological first-line treatment:
- Cognitive behavioural therapy (CBT) (strong evidence for anxiety management).
- Mindfulness and relaxation techniques (breathing exercises, guided meditation).
- Lifestyle modifications (regular exercise, sleep hygiene, reducing caffeine/alcohol).
- Pharmacological options (if symptoms are moderate-severe or impair daily function):
- First-line: SSRIs (e.g., sertraline, escitalopram).
- Second-line: SNRIs (e.g., venlafaxine) if SSRI not tolerated.
- Avoid benzodiazepines due to dependence risk.
Q3: How would you explain cognitive behavioural therapy (CBT) and its role in anxiety management?
The competent candidate should:
- Explain CBT in simple terms:
- Helps identify and challenge unhelpful thoughts that contribute to anxiety.
- Uses practical strategies to reduce avoidance behaviours and manage worry.
- Effectiveness:
- Equally effective as medication for mild-moderate GAD.
- Provides long-term coping skills, whereas medications only manage symptoms.
- Referral pathways:
- Mental Health Care Plan (Medicare-subsidised sessions).
- Online CBT programs (e.g., MindSpot, This Way Up) for mild cases.
Q4: What lifestyle modifications can help reduce anxiety symptoms?
The competent candidate should:
- Exercise:
- 150 minutes of moderate-intensity activity per week (reduces cortisol, improves mood).
- Dietary changes:
- Reduce caffeine and alcohol (can worsen anxiety symptoms).
- Maintain balanced meals (stable blood sugar levels prevent anxiety spikes).
- Sleep hygiene:
- Establish consistent bedtime routine, avoid screens before bed.
- Social support and self-care:
- Encourage hobbies, social engagement, relaxation techniques.
Q5: When would you consider referral to a psychiatrist?
The competent candidate should:
- Failure to respond to first-line treatments (CBT + SSRI) after 8-12 weeks.
- Severe functional impairment (unable to work or maintain daily activities).
- Complex comorbidities (e.g., PTSD, personality disorders).
- Suicidal ideation or high-risk features requiring specialist care.
SUMMARY OF A COMPETENT ANSWER
- Confirms GAD diagnosis using structured history and validated screening tools.
- Implements evidence-based non-pharmacological interventions before considering medication.
- Explains CBT in a patient-centred manner and facilitates access to therapy.
- Promotes lifestyle modifications to support long-term anxiety management.
- Recognises when referral to a psychiatrist is necessary for complex or treatment-resistant cases.
PITFALLS
- Prescribing benzodiazepines inappropriately instead of first-line treatments.
- Failing to rule out medical conditions (e.g., hyperthyroidism, medication side effects).
- Not exploring psychosocial contributors (e.g., work stress, relationships).
- Ignoring lifestyle interventions (exercise, diet, sleep).
REFERENCES
- RACGP Mental Health Guidelines
- Australian Psychological Society on CBT for Anxiety
- MindSpot (Online CBT Program)
MARKING
Each competency area is on the following scale from 0 to 3.
☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated
1. Communication and Consultation Skills
1.1 Engages the patient in a supportive discussion about anxiety symptoms.
2. Clinical Information Gathering and Interpretation
2.1 Conducts a structured assessment to confirm diagnosis and rule out medical causes.
3. Diagnosis, Decision-Making and Reasoning
3.1 Differentiates GAD from other anxiety disorders and psychiatric conditions.
4. Clinical Management and Therapeutic Reasoning
4.1 Develops a stepwise management plan, prioritising non-pharmacological interventions.
5. Preventive and Population Health
5.2 Encourages lifestyle modifications and self-care strategies.
6. Professionalism
6.3 Provides ethical, patient-centred mental health care.
7. General Practice Systems and Regulatory Requirements
7.2 Refers for psychological therapy under Medicare Mental Health Care Plan.
9. Managing Uncertainty
9.1 Recognises when specialist referral is necessary.
10. Identifying and Managing the Patient with Significant Illness
10.3 Identifies red flags for severe anxiety or psychiatric comorbidities.
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD