Trauma & Anxiety · Hayward, CA
Sometimes anxiety does not improve because the treatment is aimed at the wrong target. A person may try an SSRI, breathing exercises, or general talk therapy and still feel constantly on edge. They may call it “anxiety,” but underneath the anxiety may be trauma — the nervous system keeps acting as if danger is still nearby.
That distinction matters. Treatment-resistant anxiety means anxiety has not improved enough after appropriate treatment. But before calling anxiety resistant, it is worth asking a different question: is this anxiety, or is trauma keeping the alarm system on?
How trauma can look like anxiety
Trauma can make the body live in a state of protection. This may look like panic, irritability, insomnia, avoidance, emotional shutdown, trouble concentrating, or constantly scanning for danger. From the outside, it can look like generalized anxiety. Inside, it often feels more specific: the body is reacting to reminders — sensations, places, people, conflict, abandonment, or situations that resemble old danger.
The VA National Center for PTSD describes avoidance as a common part of PTSD, where people stay away from memories, feelings, and situations connected to trauma.[1] That avoidance can bring short-term relief, but it keeps the brain from learning that the present is different from the past.
When treatment doesn’t reach the real fear.
| What it looks like | What may be driving it |
|---|---|
| Panic, irritability, insomnia, trouble concentrating | A nervous system stuck in a state of protection, not just “stress” |
| Constant scanning for danger | The body reacting to reminders of old danger, not present threats |
| Avoidance that brings short-term relief | The brain never learning the present is different from the past |
| No real response to an SSRI or general talk therapy | Treatment aimed at “anxiety” while trauma keeps the alarm on |
Why exposure therapy matters
This is why our team often strongly recommends exposure-based therapy when fear and avoidance are central. Anxiety and trauma are not only chemistry problems — they are also learning problems. The brain learned, “This is dangerous.” Avoidance keeps confirming that lesson.[2]
Exposure therapy helps the nervous system learn something new: this is painful or uncomfortable, but I can face it safely.[2] For PTSD, this may involve trauma-focused therapy such as prolonged exposure — the person gradually approaches trauma-related memories, feelings, and situations they have been avoiding, so they can gain more control over the fear.[1] Medication may lower the volume. Exposure-based work helps retrain the alarm system.
Where SPRAVATO may fit
If trauma-related anxiety is happening alongside treatment-resistant depression, another option to discuss may be SPRAVATO, the FDA-approved esketamine nasal spray for adults with treatment-resistant depression.[3]
SPRAVATO is not a general anxiety or PTSD treatment. But it may matter when anxiety, trauma symptoms, and severe depression are tangled together. Esketamine affects glutamate signaling and is discussed in terms of neuroplasticity — the brain’s ability to form and update patterns.[3] That does not replace therapy. If anything, it makes the therapy piece more important: when the brain is more open to change, the experiences you repeatedly practice matter even more.
When the next step is a better map, not more medication.
- Symptoms tied to reminders — places, people, sensations, or conflict that resemble old danger.
- Avoidance still runs the day — staying away from memories, feelings, or situations keeps life small.
- Therapy never reached the fear — talk-only support without exposure or trauma-focused work.
- Depression is also present — and may be tangled together with the anxiety and trauma.
- The body stays activated — sleep, substances, medical issues, or ADHD keeping the system on edge.
- Trauma-focused options — prolonged exposure and exposure-based therapy to gradually face what’s been avoided.
What to recheck before calling anxiety “resistant”
If anxiety treatment has not worked, a provider may need to ask: Are symptoms tied to trauma reminders? Is avoidance still controlling life? Did therapy actually include exposure or trauma-focused work?[2] Is depression also present? Are sleep, substances, medical issues, or ADHD keeping the nervous system activated? And is the fear about the future, the body, social judgment, or the past returning into the present? These questions help clarify the real treatment target.
The takeaway
Treatment-resistant anxiety is real, but sometimes the anxiety is not the whole story. If trauma is keeping the alarm system on, the next step is usually not just more medication. It may be a more accurate map: trauma-focused therapy, exposure-based work, support for sleep and daily rhythm, and, when treatment-resistant depression is also present, a discussion about options like SPRAVATO or TMS. The goal is not only to feel calmer. The goal is to help the nervous system learn that the present is not the past.
Stuck on anxiety that won’t lift?
If treatment hasn’t reached the real fear, the answer may not be more medication — it may be a more accurate map. We’ll look at what’s actually driving the alarm and build a plan around it, including trauma-focused care when that’s the missing piece.
References
- U.S. Department of Veterans Affairs, National Center for PTSD. Prolonged Exposure (PE) for PTSD. ptsd.va.gov (prolonged_exposure).
- Craske MG, Treanor M, Conway CC, Zbozinek T, Vervliet B. Maximizing exposure therapy: an inhibitory learning approach. Behav Res Ther. 2014;58:10-23. PMID: 24864005 · doi:10.1016/j.brat.2014.04.006.
- U.S. Food and Drug Administration. SPRAVATO (esketamine) nasal spray — Highlights of Prescribing Information. Revised 2025. accessdata.fda.gov (211243s019lbl.pdf). (J&J standalone monotherapy approval for treatment-resistant depression announced January 21, 2025.)
Comments are closed