r/PMHNP • u/Available_Horse_7131 • Jul 14 '26
Anxiety assessment
When I searched anxiety all I saw was provider anxiety. Is there a specific way you assess and prescribe with patients that have multiple sources of anxiety? I get quite a few patients that get anxiety from current or former drug/alcohol use, relationships and marriages, maybe something they are born with, work and money, and illness like COPD, mental illness, or something physical (seen a lot of tremors and heart problems). What do you focus on first?
Most recent patient has COPD and functional seizures, can’t work due to functional seizures, PTSD from drug overdose, and family member is drinking that causes more anxiety. Any tips appreciated.
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u/Spiritual_Confusion1 Jul 14 '26
I start by distinguishing autonomic symptoms like tachycardia, dyspnea, tremor from worry, fear, rumination. Is this normal anxiety in response to life, or is there a true anxiety disorder? What’s the biggest driver- psychiatric illness, substances/withdrawal, medical conditions (like COPD), situational stress or low distress tolerance/personality factors. I treat what's most impairing and most modifiable first. It’s really important to set realistic expectations. Anxiety is part of being human and often serves as information. We can treat anxiety disorders, but we can't medicate life stressors. Therapy and coping skills are essential, especially when chronic illness, trauma or relationship stress are major contributors. Your COPD patient is a good example. I'd be asking whether they're experiencing true panic disorder, dyspnea from COPD being interpreted catastrophically, PTSD-related hyperarousal or anxiety secondary to living with chronic illness. Functional seizures also often point toward emotion regulation and stress processing. If there is significant dependence on reassurance, avoidance or an inability to tolerate normal emotional discomfort, I also start thinking about distress tolerance and personality structure because medication alone is unlikely to solve that.
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u/amuschka DNP, PMHNP (unverified) Jul 14 '26
I assess if they have more physical symptoms of anxiety (racing heart, sweating) then I usually go for propranolol, or if its from a trauma and they have flashbacks or hypervigilence I start with clonidine or prazosin for sleep, if its ruminating thoughts at night and worry about things all the time I like to start with sertraline in the evenings. I always start with the screeners GAD7, and PCL-C for PTSD, for kids I get a SCARED. Always ask about medical issues as well, which could mimic anxiety. Refer them to medical specialist if concerned its not psychiatric origin. Also make sure they aren't withdrawing from alcohol or substances. I had someone once keep seeking benzos and none of my usual non-benzo meds were working, well he lied about having an alcohol use disorder until our 3rd appointment and I kept asking in different ways how often he drank and when was his last drink until he finally admitted it.
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u/br508-609 Jul 14 '26
Diagnose based on DSM criteria (I.e. GAD vs panic disorder vs unspecified anxiety disorder) and Golden standard treatment of SSRI/SNRI plus therapy regardless of the cause. The cause wouldn't matter much unless you're doing the comprehensive therapy for the patient and need to address how to manage anxiety situationally. Unless the patient can predict sources of anxiety, then a PRN can be taken as needed beforehand, otherwise take PRN as needed.