When Trauma Looks Like Depression or Anxiety: APA 2026

TL;DR

• Trauma can present as almost any psychiatric diagnosis — depression, anxiety, ADHD-like inattention, "voices" that sound like psychosis, substance use, eating problems. The same person can carry multiple labels for what is fundamentally a trauma response.
• The current diagnostic system (DSM) often misses this. It focuses on what symptoms look like on the surface, not what's underneath. Patients can end up with three or four diagnoses and four or five medications without anyone naming the trauma at the center.
• Treatment-resistant cases are disproportionately trauma cases. When standard medications produce limited, inconsistent, or paradoxical effects, an unexamined trauma history is often the missing piece.
• The relationship between patient and prescriber matters as much as the medication itself. Trauma shapes how patients trust (or don't trust) doctors and medications. Ignoring that is a setup for non-response.
• For ketamine and psychedelic therapies, this matters even more. The subjective experience and the relationship with the prescriber are central to the treatment, not peripheral. Patient selection, informed consent, preparation, and integration become essential.

This is part of a series of patient-facing posts translating what was discussed at the American Psychiatric Association's 2026 Annual Meeting in San Francisco.

The session

The talk — "Behind the Mask: When Trauma Looks Like Depression, Anxiety, ADHD, or Psychosis" — was led by four senior researchers and clinicians:

• Rachel Yehuda, PhD (Mount Sinai) — one of the world's leading PTSD researchers
• David Mintz, MD (Director of Psychiatric Education, Austen Riggs Center) — a major voice on the psychodynamics of prescribing
• Lauren Lepow, MD, PhD (Parsons Research Center for Psychedelic Healing, Icahn School of Medicine at Mount Sinai)
• Emily Haas, MD

The overarching message: psychiatric diagnosis is often the wrong starting point for patients with trauma histories. The diagnosis describes the surface — what symptoms look like in a brief office visit. It misses what's actually generating those symptoms.

"If trauma is the forest, these disorders are the trees"

Dr. Mintz used this image to capture the problem. Trauma can produce:

• Depression (often presenting as "anhedonia" or hopelessness)
• Anxiety disorders (generalized, panic, social)
• PTSD (the only DSM diagnosis that explicitly requires a trauma)
• Dissociation (feeling unreal, disconnected, missing time)
• Somatization (chronic physical symptoms without a clear medical cause)
• Substance use disorders (self-medication of underlying distress)
• Eating disorders (regulating overwhelming emotion through food)
• Psychosis-like symptoms — particularly voice-hearing
• "Personality disorders" (especially borderline and avoidant patterns)
• ADHD-like inattention (hypervigilance is exhausting; concentration suffers)

A patient with serious developmental trauma may show up at a psychiatrist's office with three or four of these simultaneously. The current diagnostic system encourages giving them all of those labels and prescribing for each separately. The trauma doesn't get treated.

What the session argued: when one of these is present, the others are likely present too. And when treatment isn't working, the missing diagnosis is often hiding underneath.

The diagnostic system's blind spot

The DSM (the diagnostic manual used in U.S. psychiatry) was deliberately built to be descriptive rather than causal. It tells you what symptoms look like, not why they're happening. This was an attempt to make diagnosis more reliable across clinicians — and it succeeded in that goal.

But there's a cost: the DSM is intentionally insensitive to developmental causation and meaning. It doesn't ask why your depression started when it did. It doesn't ask whether your "auditory hallucinations" sound like your father's voice. It doesn't ask whether your "ADHD" appeared after a divorce or a death.

For patients with simple, time-limited illness — say, postpartum depression in someone with no trauma history — this descriptive approach works fine. For patients with complex developmental trauma, it can be actively misleading.

Voice-hearing: a clinical example

Yehuda and colleagues used voice-hearing as a central example. About 70-90% of people with severe trauma histories report some form of voice-hearing at some point. The voices are often qualitatively different from the voices in primary psychotic disorders like schizophrenia:

Feature	Trauma-related voices	Primary psychosis voices
Content	Often the abuser's voice, or fragments of trauma	Often unfamiliar, ego-alien
Quality	Patient can usually recognize they're "their own"	Patient typically experiences as external/foreign
Onset	Often tied to dissociative state or trigger	More autonomous, can occur in any state
Dissociative features	Often accompanied by depersonalization	Less commonly tied to dissociation
Response to antipsychotics	Often minimal	Often substantial
Response to trauma treatment	Often substantial	Limited

A patient with trauma-related voice-hearing who gets diagnosed with schizophrenia may end up on antipsychotic medications for life when what they actually needed was trauma-focused therapy. This is one of the highest-stakes diagnostic errors in psychiatry, and it happens regularly.

Treatment resistance in trauma

A consistent finding in the research: patients with trauma histories show higher rates of treatment resistance to standard psychiatric interventions. This isn't because trauma "ruins" treatment response. It's because:

1. The treatments aren't addressing what's actually going on. Antidepressants for depression-driven-by-trauma have a partial effect at best.
2. Trauma shapes how patients engage with treatment. Medications can feel intrusive; doctors can feel like authority figures who will harm you; recovery can feel unsafe.
3. The prescribing relationship itself becomes a site of re-enactment. Patients with insecure attachment histories may unconsciously recreate harmful dynamics in their relationship with the clinician.

Dr. Mintz's framework breaks treatment resistance into three sources:

Treatment resistance TO medications

• Ambivalence about the medication itself ("Is this safe? Will it change who I am?")
• Ambivalence about the prescriber ("Can I trust this person?")
• Ambivalence about the illness ("If I get better, what does that mean about what I've been through?")

Treatment resistance FROM medications

• Medication use becomes symptomatic — it serves a defensive or avoidant purpose rather than a therapeutic one
• A patient using a sedative to avoid feeling anything isn't actually getting "treated"
• This can lead to what Mintz calls "psychiatric chronification" — staying on medications without improving

The treater's contribution

• Failures of integration (treating depression without seeing the trauma)
• Failures of empathy
• Patient feels "managed" rather than understood

The takeaway: when treatment isn't working, it's worth asking what role the treatment relationship itself is playing, not just whether the medication choice was right.

What works better

The session laid out six principles for trauma-informed prescribing:

1. Avoid a mind-body split

Trauma is biological and psychological. The biology includes:

• HPA dysregulation (the body's stress response system)
• Hyperactive amygdala (the brain's threat detector)
• Shrunken hippocampus (the brain's memory center)
• Reduced prefrontal cortex volume (the brain's regulator)
• Sympathetic dominance (the body stays in "fight or flight")

These are real, measurable changes. The psychology includes defenses, dissociation, repetition compulsion, and attachment patterns. Both layers need to be in the formulation.

2. Know who the patient is, not just what they are

Listening on all levels:

• What they say
• Non-verbal communication
• Countertransference (what the patient evokes in the clinician)

Developmental history matters: when did the first psychiatric struggle appear? What was happening then? How does that affect how the patient relates to authority figures and caregivers now?

3. Attend to ambivalence

Ambivalence about treatment isn't a problem to overcome — it's information. It tells you about the patient's relationship to medications, treaters, and recovery. Naming and exploring it often does more therapeutic work than trying to push past it.

4. Foster alliance

"The doctor is the drug" — a phrase from Michael Balint (1957). Healing relationships themselves reduce HPA activation and trauma-related epigenetic changes. The relationship has biological effects, not just emotional ones.

For patients who have been disempowered, empowerment is part of treatment. Eliciting and respecting medication preferences, educating about alliance, authorizing the patient to protest — these aren't soft skills. They're the active ingredients in many cases.

5. Attend to counter-therapeutic uses of medications

Sometimes medications serve the function of a symptom — substituting for human connection, blocking emotional access that needs to happen for healing, or telling a story of being harmed that the patient can't yet put into words.

6. Manage countertransference in prescribing

Patients with overwhelming affects induce corresponding affects in their doctors. Recognizing this — and consulting with colleagues when it happens — is part of good care.

What this means for ketamine and psychedelic therapy

Dr. Lepow's portion focused on the unique risk-benefit profile of ketamine and psychedelics in patients with complex trauma histories. The points that matter for patients considering treatment:

Models of care matter

The medical model — induction series of ketamine treatments followed by maintenance dosing, focused on symptom reduction — works well for many patients. But for patients with serious trauma histories, there's a risk:

• Symptom reduction can become the entire goal
• "Numbing" gets confused with healing
• The exploration that would actually integrate the trauma never happens

This is why the therapeutic context around ketamine matters more for trauma patients than for patients with straightforward depression. A simple infusion that reduces depression scores isn't necessarily working at the level the trauma requires.

What MADRS misses

Standard depression rating scales (like MADRS) measure symptom severity. After a ketamine session, the score can drop because the patient is feeling better — or because the patient has dissociated. The scale can't tell the difference.

A more nuanced view: a temporary rise in distress after a session can actually be a positive sign. It can mean: "I'm finally in touch with what I've been protecting myself from, and now I can work on it." That's not treatment failure — that's the beginning of real treatment.

What this means for choosing care

For patients with significant trauma histories considering ketamine or psychedelic therapy:

• Patient selection matters. Not every patient with depression should be in a high-dose dissociative protocol on their first session.
• True informed consent matters. Patients deserve to know that strong material can surface and what the support around that will look like.
• Preparation matters. Multiple sessions of prep work with a therapist, not just a quick intake.
• Containment matters. Knowing that the team can hold what comes up — and what to do if it doesn't subside on its own.
• Integration matters. Sessions in the days and weeks after, not just before.

This is also a strong argument for working with a physician-led program that takes patient history seriously, rather than a quick-infusion clinic. The medicine is the same; the safety profile depends on the surrounding care.

What this means for patients

If you've been bouncing through psychiatric labels — depression that doesn't respond to antidepressants, anxiety that won't quit, ADHD that didn't show up until adulthood, voices that don't fit a primary psychotic disorder, multiple diagnoses that don't really cohere — ask yourself and your clinician:

1. What was happening when these symptoms first appeared?
2. Have you been asked about developmental experiences (childhood adverse events) in any meaningful way?
3. When treatment isn't working, what does your clinician think is going on — and does that explanation match what you experience?
4. Are you being treated for symptoms or for the underlying organizing factor?
5. Does the relationship with your prescriber feel like one in which you can disagree, ask questions, and bring difficult material?

You are entitled to ask those questions. A diagnosis that doesn't explain your experience to you is incomplete. A treatment that doesn't acknowledge the relational dimension is operating with one hand tied behind its back.

Sources cited

• Yehuda R et al. — extensive published work on PTSD biology, epigenetics, and intergenerational trauma transmission
• Mintz D, Belnap B. Psychodynamic Psychiatry 2006 — Treatment resistance and psychodynamics of prescribing
• Mintz D. American Journal of Psychotherapy 2022 — Psychodynamic prescribing in practice
• Balint M. The Doctor, His Patient and the Illness. 1957 — Foundational work on the therapeutic relationship
• Shinn AK et al. — Work distinguishing trauma-related voice-hearing from primary psychosis
• Mathai DS et al. Frontiers in Psychiatry 2022 — Towards synergies of ketamine and psychotherapy
• Modlin NL et al. 2025 — Symptoms as coping strategies in psychedelic treatment
• Berman RM et al. Biological Psychiatry 2000 — Foundational ketamine trial
• Zarate CA et al. Archives of General Psychiatry 2006 — Ketamine in TRD
• Feder A et al. Am J Psychiatry 2014 / 2021 — Ketamine for chronic PTSD
• Dore J et al. J Psychoactive Drugs 2019 — Ketamine-assisted psychotherapy framework

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