Even though Ketamine is a "Dissociative" drug, can you still use it in patients with Dissociation?

Ketamine-Yes youc an use it in patients with dissociation-

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A common question that arises is the confusion over the dissociative effects of Ketamine and how that relates to the symptoms of dissociation in a patient with mental health symptoms. The two words are the same but mean completely different things!

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In short one can look at it this way:

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On a very simple level trauma-based dissociation, which is a form of hyper compartmentalization of different aspects of a traumatic experience (for the sake of psychological or physical survival after overwhelm and endangerment or various forms of traumatic injury and intrusion, threat etc.) is very different from the benevolent, kind of pharmaceutically or biologically mediated dissociation, which helps people separate from at lower doses, their ruminative calculative, obsessive, thinking, and constricted consciousness and at a higher dose, helps people separate from their biographies, and their sense of being limited by time, space, and identity, and so that type of dissociation lubricates the therapeutic process. Whereas the first type of traumatic dissociation , protects peoples’ sanity, and sense of self from further re-traumatization or protects from further disintegration under the pressure of trauma or post traumatic navigation of life.

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On a deeper level in the process of using ketamine during ketamine assisted therapy, dissociation can be viewed pharmacologically.

Ketamine-induced dissociation is a pharmacological, dose-dependent state. Ketamine is an NMDA receptor antagonist, and at the right doses it produces a temporary, predictable alteration in consciousness—a sense of detachment from the body, distortions of time and space, perceptual changes, sometimes the "K-hole" at higher doses. It comes on as the drug takes effect, peaks, and resolves as the drug clears, typically within an hour or so for the acute effects. In a clinical or therapeutic context it's intentional and contained, and many practitioners consider the dissociative state part of how ketamine may open a window for therapeutic work. The person usually knows why it's happening and it ends reliably. The dissociative state in this sense speaks to a disconnection from conscious awareness and the body. Yes this can seem similar to a person struggling with dissociation mentally however the underlying process is completely different. There is no protective part coming online to defend against danger here. There is increased capacity, ability to hold and experience and a softer move into what may be felt as difficult. There is a literal disconnection from body pharmacologically but again not something happening as a result of fragmented protective mechanisms in one's experience driving the show.

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In contrast, dissociation as a mental health symptom is a protective response of the nervous system, not a drug effect. It exists on a spectrum from mild, common experiences like spacing out or highway hypnosis, to depersonalization (feeling detached from yourself), derealization (the world feeling unreal or dreamlike), to more severe presentations like dissociative amnesia or the identity fragmentation seen in dissociative identity disorder. It's frequently rooted in trauma: the system learned to disconnect as a way to survive overwhelming experience. It tends to arise unbidden, can be triggered by stress or reminders of trauma, isn't time-limited in a predictable way, and often feels distressing or out of the person's control.

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Given there is similiarity between the felt experience, careful preparation, resourcing with the felt sense and education around expectations and knowing what is going to happen, that it will have a beginning and an end and that there is empowerement and relationship throughout the process. These are what makes it a powerful repairative experience for clients. After working with ketamine assisted therapy, people often have reduced dissociation since the complex trauma driving the need to protect starts to soften as it experiences more felt safety in the world.

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It is a topic that reminds of the nuance of this work.

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Michael Yasinski MD

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