Health Anxiety — Free SCA Practice Case
Childhood Leukaemia Survivor with Health Anxiety
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Liam Davies
Age
28 years
Consultation Type
VideoAge
28
Situation
Video Consultation.
Reason for Encounter
"Patient booked a video appointment to show you a bruise on his leg that he says isn't healing. This is his 4th consultation in 6 weeks for minor ailments (previously seen for a mild headache, a mouth ulcer, and feeling tired)."
Medical Records
- ●PMH: Acute Lymphoblastic Leukaemia (ALL) diagnosed at age 5. Treated with systemic chemotherapy (including anthracyclines) and prophylactic cranial radiotherapy. In remission for over 20 years.
- ●Medications: None.
- ●Allergies: NKDA.
Recent Notes
- ●Routine bloods (FBC, U&Es, LFTs) done 6 months ago at a routine well-man check: All entirely normal.
Patient Script
For the friend playing the patient role
Character Overview: You are Liam, a 28-year-old software developer. To the outside world, you are a healthy, successful young man who beat childhood cancer. Internally, you are trapped in a cycle of severe health anxiety. You have a tiny, faint, yellowish-green bruise on your left shin. You bumped it on your desk a week ago, but because it hasn't completely faded, your brain has spiraled into absolute terror. You are secretly convinced that the leukaemia has returned. This terror is what drives you to the GP every few weeks for minor things (headaches, mouth ulcers). You desperately want a doctor to run a blood test today to prove you aren't dying. You are deeply ashamed of your anxiety. You know the doctors think you are a hypochondriac, so you try to act casual and downplay your fear. You will not volunteer that you are terrified of a cancer relapse unless the doctor actively explores your underlying concerns, picks up on your non-verbal hesitation, or specifically links your frequent attendance to your childhood history.
Consultation Flow & Responses:
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The Opening:
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If the doctor asks an open question: "Hi Doctor. Sorry to bother you again. I know I was only on the phone a couple of weeks ago. I've just got this bruise on my shin. I bumped it on my desk last week and it's just taking ages to go away. I wanted to get it checked out just in case."
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Data Gathering (The Layers):
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If asked to describe the bruise: It is a very faint, resolving, 2cm yellowish-green bruise on your shin. Nothing alarming.
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If asked about other bleeding/bruising: "No, no other bruises. My gums don't bleed when I brush them."
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Layer 1: The Red Flag Screen (B-Symptoms):
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If asked about weight loss, night sweats, or bone pain: "No, my weight is stable. No sweats in the night. The only thing is I'm feeling really tired, but I haven't been sleeping well lately."
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Layer 2: The Psychosocial Cue:
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If asked WHY you aren't sleeping: You look away from the camera, rubbing your neck, clearly hesitant. "Just... stress, I guess. Work is busy, but mostly my mind just won't switch off when I lie down. I just keep thinking about things."
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Layer 3: Exploring ICE & The Core Fear - ONLY REVEAL IF ASKED:
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If the doctor asks: "What are you worried this bruise might mean?" or "Does this tie back to your history of leukaemia?"
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Reaction (The Reveal): Your casual facade drops. You look tearful. "I know it sounds stupid because it was over 20 years ago. But every time I get a mouth ulcer, or a headache, or a bruise... I am instantly 5 years old again, sitting in that hospital ward. I am terrified the leukaemia is back. I just need you to order a blood count so I know I'm not relapsing. Please."
ICE — Ideas, Concerns, Expectations
The patient does not raise these unprompted. These responses surface only when the candidate directly explores the patient's perspective.
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Ideas: Liam believes the bruise is not healing because something is wrong with his blood. Deep down, he thinks the leukaemia has come back — he associates any unexplained physical symptom with a relapse. He cannot rationalise his way out of this belief despite knowing intellectually that it was over 20 years ago.
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Concerns: His overriding fear is that the cancer has returned and that this bruise is the first sign. Beyond the immediate health scare, he is worried that he is losing control — that this cycle of panic over every minor symptom is taking over his life and that he will never feel safe in his own body. He is also deeply ashamed that he can't just "get over" something that happened when he was five.
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Expectations: He wants a blood test today — specifically a full blood count — to prove he is not relapsing. That is his immediate, non-negotiable expectation coming into this consultation. However, if the doctor validates his distress and offers a meaningful path forward (such as therapy), he is open to a longer-term plan provided he gets the reassurance of one final test today.
If Asked — Medical History and Medications
The patient does not volunteer medical history detail unprompted. These responses are actor guidance for when the candidate directly asks about specific items.
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If asked about the childhood leukaemia and its treatment: "I was diagnosed when I was five. I had chemotherapy — I don't remember all the names, but my mum has told me it was quite intensive. I also had radiotherapy to my head. They said it was to stop it spreading to my brain. I was in and out of hospital for about two years. I've been in remission ever since — over twenty years now."
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If asked about long-term follow-up or late effects monitoring: "I used to go to a late effects clinic at the hospital, but I got discharged from that about five years ago. They said everything looked fine and I didn't need to keep coming back. My GP does a check-up once a year or so."
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If asked about the recent blood tests (6 months ago): "Yeah, I had bloods done at my well-man check about six months ago. The doctor said everything was completely normal — blood count, kidneys, liver, all fine."
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If asked about current medications: "I'm not on anything. No regular medications at all."
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If asked about allergies: "No, no allergies to anything."
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If asked about the previous consultations (headache, mouth ulcer, tiredness): "The headache was about six weeks ago — it lasted a couple of days and then went on its own. The mouth ulcer was a few weeks after that, just a normal one on the inside of my cheek. And the tiredness... I mean, I am tired, but I think that's because I'm not sleeping. Each time I came in, the doctor said it was nothing serious, and I know they were right, but it doesn't stop me worrying about the next thing."
Social History and Lifestyle Impact
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Occupation and daily life: Liam works as a software developer for a mid-sized tech company. He works from home most days, which means he spends long stretches alone at his desk. He lives with his girlfriend in a rented flat. He doesn't smoke, drinks socially at weekends — maybe two or three pints — and doesn't use recreational drugs.
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Lifestyle impact of the condition: The health anxiety is significantly disrupting Liam's daily functioning. He spends hours each evening googling symptoms and reading about leukaemia relapse rates. His girlfriend has started to notice and they have argued about it — she thinks he is obsessing and he feels she doesn't understand. At work, he finds it hard to concentrate because his mind drifts to whatever symptom he is fixating on that week. He has also started avoiding exercise because he is afraid that any new ache or bruise will set off another spiral. If asked directly: "Honestly, it's taken over. I can't stop checking things — I'll be in the middle of a code review and suddenly I'm on Google reading about relapse symptoms. My girlfriend is getting fed up with it. She says I need to stop but I can't just switch it off. I used to play five-a-side football every week but I've stopped going because last time I got a dead leg and I couldn't cope with the bruise — I spent the whole weekend convinced it was something sinister."
If Asked — Associated Symptoms
The patient does not volunteer these details unprompted. These are actor guidance for when the candidate asks directly about specific symptoms.
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If asked about fever or recurrent infections: "No, I haven't had a temperature or anything like that. I don't seem to pick up colds or infections more than anyone else."
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If asked about petechiae or a rash: "No, no rash or little red dots or anything like that — just this one bruise where I banged it."
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If asked about nosebleeds or bleeding gums: "No nosebleeds. My gums don't bleed when I brush my teeth either."
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If asked about lumps or swollen glands: "No, I haven't noticed any lumps anywhere — not in my neck or under my arms or anything."
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If asked about abdominal pain or feeling of fullness: "No, my stomach feels fine. No pain or bloating or anything unusual."
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If asked about shortness of breath: "No, not really. I mean, I get out of breath if I run for the bus, but nothing unusual. I'm just not as fit as I used to be because I've stopped playing football."
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If asked about joint or bone pain: "No, no pain in my joints or bones. Nothing like that."
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If asked about appetite changes: "My appetite is fine — if anything I'm eating more because I'm comfort eating when I'm stressed."
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If asked about changes in bowel habit or urine: "No, all normal. Nothing different there."
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If asked about headaches (beyond the previous consultation): "I get the odd headache, but nothing severe or persistent. The one I came in about before went away on its own after a couple of days."
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If asked about vision changes: "No, my eyesight is fine."
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If asked about skin changes beyond the bruise: "No, just this bruise. No other marks or changes anywhere."
Negotiation & Collaborative Management Plan:
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If the Doctor dismisses the fear ("It's just a bruise, your bloods were fine 6 months ago, you don't need a test"):
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Reaction: Defensive and panicked. "But things can change in 6 months! Leukaemia happens quickly! If you won't do the test, I'll just go to A&E." (Candidate fails for failing to address the psychological reality of the patient's fear).
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If the Doctor just agrees to the blood test without addressing the anxiety loop:
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Reaction: "Thank you. I'll get it done tomorrow." (Candidate critically fails for feeding into the health anxiety reassurance-seeking cycle without treating the underlying psychological trauma).
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If the Doctor validates the trauma and suggests Cognitive Behavioural Therapy (CBT) for Health Anxiety:
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Reaction: "You think it's trauma? I always thought I should just be 'over it' by now. But it really is ruining my life. If I talk to a therapist, do you think it will stop me panicking over every little bump?"
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If the Doctor offers a compromise (Shared Decision Making):
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Reaction: "So we'll do one final blood test today for my peace of mind, but we agree that moving forward, I start therapy for the anxiety instead of coming in for every symptom? Yes, I think I can agree to that."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Diagnosing Health Anxiety (Illness Anxiety Disorder) — Recognising the Pattern
- ●Illness anxiety disorder (formerly hypochondriasis) is characterised by persistent preoccupation with having or acquiring a serious illness, disproportionate to any objective clinical findings. In this case, Liam's repeated attendance for minor, self-limiting symptoms is the diagnostic signal — not the individual complaints themselves.
- ●The pattern of frequent attendance for unrelated minor ailments is clinically meaningful and should be treated as a diagnostic sign in its own right, prompting exploration of the underlying psychological driver rather than repeated episodic reassurance.
- ●Health anxiety rooted in childhood illness trauma may present with features overlapping PTSD — intrusive recollections (feeling "instantly 5 years old again"), hypervigilance to bodily sensations, and avoidance behaviours (stopping football to avoid bruising). Recognising this dual framing changes the management approach.
The Reassurance-Seeking Cycle — Why Investigations Perpetuate the Problem
- ●Providing medical reassurance — whether verbal ("the bruise is fine") or investigative (ordering an FBC) — offers only short-term relief in health anxiety. The anxiety reliably transfers to a new somatic symptom within days to weeks.
- ●Each test ordered reinforces the patient's core belief: "there is something physically wrong with me that needs testing." Over time, this deepens the anxiety disorder rather than resolving it.
- ●The correct therapeutic approach is to explicitly name this cycle to the patient in a non-judgemental way, framing the management plan as designed to address the underlying anxiety — not to accumulate negative test results.
- ●An FBC may be negotiated as a one-off transitional reassurance tool, provided it is paired with a committed psychological treatment plan and explicit agreement that future symptoms will be managed through therapy rather than further testing. Ordering bloods without this framing is a clinical failure.
First-Line Management — CBT via NHS Talking Therapies (IAPT)
- ●Cognitive Behavioural Therapy (CBT) is the NICE-recommended first-line treatment for health anxiety (NICE CG53 / NICE NG197). It targets the catastrophic misinterpretation of benign bodily sensations and the safety behaviours (googling, attendance, reassurance-seeking) that maintain the disorder.
- ●The referral pathway is self-referral to NHS Talking Therapies (formerly IAPT) — direct the patient to the local service or NHS website. GP-facilitated referral is also appropriate where self-referral is not available locally.
- ●When explaining the referral, name CBT specifically and explain what it targets: the brain's "threat detection system" firing inappropriately in response to minor physical sensations, driven by past trauma. Vague references to "counselling" or "therapy" without specifying CBT or the referral pathway leave the patient without an actionable next step.
- ●For health anxiety with significant PTSD features (as in this case), trauma-focused CBT or EMDR may be more appropriate and can be discussed at assessment. The GP does not need to determine this — the IAPT service will triage accordingly.
Explaining the Bruise — Addressing the Specific Cognition
- ●A yellowish-green bruise represents the breakdown of haemoglobin from the initial haematoma: oxyhaemoglobin → biliverdin (green) → bilirubin (yellow) before full reabsorption. This is a normal, predictable physiological sequence.
- ●A minor traumatic bruise typically takes 7–14 days to fully resolve, depending on size and depth. The colour change signals active healing, not pathology.
- ●Explaining this physiology directly addresses Liam's specific fear — that the bruise "isn't healing" — and provides a rational counter-narrative to the catastrophic interpretation. Generic reassurance ("it's fine") without this explanation misses the therapeutic opportunity.
Late Effects of Childhood ALL — Survivorship Awareness
- ●Survivors of childhood Acute Lymphoblastic Leukaemia (ALL) treated with anthracyclines (e.g., doxorubicin, daunorubicin) and cranial radiotherapy carry significant long-term health risks that may manifest decades after treatment:
- ●Cardiotoxicity: Anthracycline-related cardiomyopathy and heart failure, sometimes presenting in the 3rd or 4th decade. Requires periodic echocardiographic surveillance.
- ●Secondary malignancies: Cranial radiotherapy confers increased risk of brain tumours and meningiomas; anthracyclines increase risk of secondary haematological malignancies.
- ●Endocrine dysfunction: Cranial radiotherapy can cause growth hormone deficiency, hypothyroidism, and early gonadal failure. Relevant even in adulthood.
- ●Neurocognitive effects: Cranial radiotherapy in early childhood is associated with long-term cognitive and executive function difficulties.
- ●Liam's late effects clinic discharge five years ago should prompt consideration of whether structured survivorship surveillance remains appropriate. For survivors of intensively treated childhood ALL, ongoing cardiology and endocrinology review is typically recommended into adulthood. A re-referral or structured GP-led surveillance plan should be considered.
- ●Acknowledging the legitimate basis for Liam's vigilance — that survivors of his treatment genuinely do have elevated long-term risks — is essential for therapeutic alliance and differentiates appropriate clinical validation from unhelpful reinforcement of anxiety.
Haematological Red Flags — Systematic Safety Screen
- ●Before attributing a bruise to anxiety, a focused red flag screen for haematological pathology is mandatory. Screen specifically for:
- ●Drenching night sweats (soaking clothing or bedding)
- ●Unexplained significant weight loss (>5% body weight over 3–6 months)
- ●Generalised bone or joint pain (not localised or mechanical)
- ●Petechiae — non-blanching pinpoint haemorrhages indicating platelet dysfunction
- ●Epistaxis or spontaneous bleeding gums beyond minor trauma
- ●Lymphadenopathy — palpable nodes in neck, axillae, or groin
- ●Recurrent or unusually severe infections suggesting immunosuppression
- ●The absence of all of the above, combined with a resolving traumatic bruise and normal FBC six months prior, makes haematological relapse clinically very unlikely. This screen must be completed before the consultation pivots to psychological management.
Breaking the Attendance Cycle — Proactive Follow-Up
- ●Reactive follow-up ("come back if you get another symptom") is counterproductive in health anxiety: it requires the patient to produce a new physical complaint in order to access care, inadvertently reinforcing symptom-focused attendance.
- ●A scheduled follow-up in 3–4 weeks — explicitly framed as a wellbeing check irrespective of new symptoms — removes this perverse incentive and begins to establish a different relational contract with the GP.
- ●This also provides an opportunity to confirm therapy referral progress, address sleep, and monitor response to the management plan.
Sleep Disruption — Immediate Practical Advice
- ●Liam's sleep disruption is driven by health-related rumination rather than primary insomnia. Practical sleep hygiene advice should be offered as part of the anxiety management plan:
- ●Consistent sleep and wake times
- ●Removing screens (especially phones) from the bedroom
- ●Explicitly advising against symptom-searching or health-related googling in bed or at night
- ●Frame this as an active component of anxiety management, not a deferred problem. Rumination at night is both a symptom and a perpetuating factor for health anxiety.
Common Candidate Mistakes in This Case
- ●Ordering the FBC without framing: The most common critical failure. Agreeing to the blood test without addressing the reassurance-seeking cycle treats the symptom, not the disorder, and sends the patient away to generate the next physical complaint.
- ●Refusing the blood test paternalistically: The opposite failure. Refusing without negotiation damages therapeutic alliance and leaves the patient's legitimate (albeit anxiously amplified) safety concern unaddressed.
- ●Naming "therapy" without specifying CBT: "I'll refer you to see someone to talk about this" is insufficient. Name CBT, explain what it addresses, and give the patient the referral pathway.
- ●Missing the dual pathology: Candidates who lock onto the physical presentation and never explore the psychological driver will fail to reach the diagnosis. The bruise is the presenting ticket; health anxiety is the clinical problem.
- ●Dismissing the late effects history as irrelevant: The childhood leukaemia is not just background context — it is the aetiological root of the anxiety and carries ongoing surveillance implications. Treating it as irrelevant misses both a therapeutic opportunity and a patient safety consideration.
Mapped to the RCGP curriculum topic: People with Long-term Conditions Including Cancer.
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