Updated for 2026
PMHNP anxiety and trauma: PTSD, GAD, panic disorder, and trauma-informed psychiatric care
Anxiety disorders and PTSD are the most prevalent psychiatric diagnoses, with high comorbidity with mood disorders and substance use. PMHNP certification tests DSM-5 diagnostic criteria for PTSD, social anxiety disorder, GAD, and panic disorder; first-line pharmacotherapy; trauma-focused psychotherapy evidence; and trauma-informed prescribing considerations.
Educational purpose: This content is for exam preparation and professional development only. It is not intended for clinical decision-making. Always follow current guidelines, institutional policies, and scope of practice.
PTSD — DSM-5 criteria and evidence-based treatment
DSM-5 PTSD criteria (adults ≥18): Exposure to actual/threatened death, serious injury, or sexual violence (directly, witnessing, learning about loved one, or repeated exposure to traumatic details). Four symptom clusters: (1) Intrusion (flashbacks, nightmares, intrusive memories, physiological reactivity), (2) Avoidance (internal avoidance of trauma-related thoughts/feelings; external avoidance of reminders), (3) Negative cognitions/mood (distorted blame, persistent negative affect, diminished interest, feeling detached, inability to experience positive emotions), (4) Arousal/reactivity (irritability, reckless behaviour, hypervigilance, exaggerated startle, sleep disturbance, concentration difficulty). Duration >1 month, significant functional impairment.
Evidence-based psychotherapy (VA/DoD CPG — first-line): Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and EMDR (Eye Movement Desensitisation and Reprocessing) are all first-line trauma-focused therapies. These are preferred over pharmacotherapy as first-line for PTSD.
First-line pharmacotherapy for PTSD (VA/DoD and APA): SSRIs — sertraline and paroxetine (FDA-approved for PTSD). SNRIs — venlafaxine (strong evidence, widely used). These reduce all four PTSD symptom clusters but are not as effective as trauma-focused therapy.
Adjunctive pharmacotherapy: Prazosin (alpha-1 blocker) for PTSD nightmares — evidence from VA trials (note: the 2018 PACT trial did not show benefit in the primary endpoint, but many clinicians still use; individualised). Avoid benzodiazepines — no evidence of benefit, risk of worsening PTSD outcomes and substance use comorbidity.
Anxiety disorders — differentiating GAD, social anxiety, and panic disorder
Generalised Anxiety Disorder (GAD): Excessive, difficult-to-control anxiety and worry about multiple domains (work, health, family), ≥6 months, ≥3 somatic symptoms (fatigue, muscle tension, sleep disturbance, restlessness, concentration difficulty, irritability). Treatment: SSRIs/SNRIs first-line for chronic GAD; buspirone is an alternative. CBT has equivalent efficacy to pharmacotherapy.
Social Anxiety Disorder (SAD): Marked fear of social situations where scrutiny/humiliation is possible; fear is out of proportion; avoidance causes significant impairment. Specific feared situations: public speaking, eating in public, meeting new people, use of public restrooms. Treatment: SSRIs/SNRIs, beta-blockers (propranolol — situational, for performance anxiety only, not chronic treatment), CBT (considered first-line especially for mild-moderate SAD).
Panic disorder: Recurrent unexpected panic attacks + persistent concern/behaviour change for ≥1 month. Panic attack: abrupt surge of intense fear/discomfort, peaking within minutes, with ≥4 symptoms (palpitations, sweating, tremor, shortness of breath, choking, chest pain, nausea, dizziness, chills/hot flushes, paraesthesias, derealisation, fear of losing control, fear of dying). Treatment: SSRIs/SNRIs + CBT (interoceptive exposure). Avoid benzodiazepines as primary treatment for panic disorder.
Frequently asked questions
- What is trauma-informed care and how does it affect PMHNP clinical practice?
- Trauma-informed care (TIC) recognises the high prevalence of adverse childhood experiences (ACEs) and traumatic events in patients with psychiatric diagnoses, and understands that many 'problematic behaviours' are adaptive responses to past trauma. The five TIC principles (SAMHSA): Safety, Trustworthiness, Peer support, Collaboration and mutuality, Empowerment. In PMHNP practice: Universal precautions — assume every patient has a trauma history until proven otherwise; do not require trauma disclosure for sensitive care practices (pelvic exams, injection, blood draws — offer choice and explanation of what you're about to do). Avoid re-traumatisation through power-imbalanced interactions. Ask 'what happened to you' not 'what is wrong with you.' Trauma history affects medication adherence, side effect perception, therapeutic alliance, and response to psychiatric treatment.
Clinically reviewed by NurseNest Clinical Review Team · Last updated 2026-06-10 · For educational purposes only · Review policy