There is a need to distinguish the difference between trauma driven dissociation and ketamine driven dissociation. How can clients with dissociation benefit from a medicine that causes dissociation? Read below for an in depth explanation from the relational KAP model weaving in neuroscience to explore the answer.

Trauma-driven dissociation is usually a defensive disconnection from experience because experience has become intolerable.Ketamine-induced dissociation is a temporary pharmacologic loosening of thebrain's ordinary integration of self, body, perception, memory, and salience.In well-held relational KAP, that loosening may allow a person who chronicallydisconnects from experience to encounter previously intolerable experiencewhile remaining connected enough to another human being, the present moment, andan observing self.

1. The word “dissociation” describes more than one brain state

Ketamine dissociation and traumatic dissociation can overlapphenomenologically as each experience of the same symptoms is unique. Symptomsof depersonalization, derealization, altered body perception, altered time, anddistance from ordinary identity, while differing profoundly in cause, context,temporal dynamics, defensive meaning, and potential function.

Trauma-related dissociation is often conceptualized as aninvoluntary defensive strategy. In the dissociative subtype of PTSD,neuroimaging literature has described patterns consistent with emotionovermodulation: increased recruitment of medial prefrontal/anterior cingulateregulatory systems together with altered or reduced limbic responsivity in someparadigms.

Ketamine, in contrast, uses NMDA-dependent corticalprocessing, inhibitory interneuron function, thalamocortical communication,sensory integration, oscillatory activity, and large-scale networkorganization. The altered state is therefore pharmacologically generated ratherthan inherently a defensive response to unbearable affect.

A useful teaching distinction:
- Trauma dissociation: “I must leave myself because this is unbearable.”
-Ketamine dissociation: “The usual architecture of self and perception istemporarily loosened.”

Ketamine dissociation is not inherently therapeutic, andgreater acute dissociation has not been established as necessary or sufficientfor clinical benefit.

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2. PTSD as a disorder ofinteracting networks

Threat and salience circuitry-Amygdala, anteriorinsula, dorsal anterior cingulate, hypothalamus, and brainstem defensivesystems participate in detecting significance and organizing threat responses.PTSD is better understood as dysregulation among interacting networks thansimply as an “overactive amygdala.”

Context circuitry- Hippocampal and medial prefrontalsystems help answer: Where am I? When am I? Is this now or then? A usefultrauma formulation is that pathological traumatic memory can involve THEN beingexperienced as NOW.

Self circuitry- Medial prefrontal cortex, posteriorcingulate/precuneus, hippocampal systems, and the broader default mode networkcontribute to autobiographical self, self-reference, mental time travel, andcontinuity of identity.

Executive/regulatory circuitry- Dorsolateralprefrontal and frontoparietal systems contribute to attention, inhibition,cognitive flexibility, and deliberate regulation. PTSD involves alteredinteraction among executive, salience, and default-mode networks.

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3. What ketamine maytemporarily do to these systems

Acute ketamine changes connectivity and activity acrossdefault-mode, salience, executive, hippocampal, insular, and thalamocorticalsystems. Individual imaging findings vary by dose, task, population, timing,and analysis method; therefore, it is more defensible to say that ketaminetransiently reorganizes ordinary network dynamics than that it simply “turnsoff” a particular network.

Trauma-related predictions can become rigid and embodied:
• This sensation means danger.
• This person will abandon me.
• If I feel this, I will disintegrate.
• Anger is dangerous.
• My body cannot be trusted.
• Surrender means helplessness.

Ketamine in the right conditions creates a novel sensory,emotional, and relational experience

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4. Plasticity biology:changing not only experience, but learning

Ketamine's NMDA-related effects can increase glutamatergicthroughput through AMPA receptors and engage downstream pathways involvingBDNF/TrkB and mTOR-related signaling. Preclinical and translational worksupports effects on synaptic remodeling and dendritic spine dynamics.

For therapists, the clinically useful translation is:ketamine may not only change what the person experiences during the session;for a period afterward, it may alter how readily neural systems learn fromexperience.

This suggests a two-part model:
1. Acute session: destabilization, flexibility, altered salience, alteredself-processing.
2. Relational experience and integration: learning, meaning-making, behavioralrehearsal, and consolidation.

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5. Why relational KAP isparamount

Consider an attachment prediction: “When I becomevulnerable, I am alone.”

Kap becomes when I am vulnerable and someone is there withme, with a positively valanced relationship

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6. The therapist as part ofthe prediction error

Attachment trauma often carries high-confidence predictionssuch as:

·       closeness → danger

·       dependency → abandonment

·       emotion → rejection

·       surrender → violation

·       being seen → shame

A corrective relational experience violates the prediction.The person becomes vulnerable, yet the therapist stays, tracks withoutintruding, respects agency, tolerates emotion, and does not disappear.

Prediction error is central to learning: when realitymeaningfully differs from expectation, the brain has an opportunity to updateits model. Relational KAP may therefore combine pharmacologically facilitatedflexibility with embodied interpersonal prediction error.

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7. Reconsolidation andextinction: access is not enough

Trauma therapy is sometimes framed as accessing traumaticmemory. Access alone does not guarantee therapeutic change.

When established memories are retrieved under particularconditions, they may become labile and potentially subject toreconsolidation/update. Extinction is related but distinct: new safety learningcompetes with older threat learning rather than necessarily erasing it.

Ketamine interacts with NMDA-dependent learning systems,making reconsolidation and extinction compelling hypotheses. However, theevidence is complex: animal work suggests ketamine can facilitate, impair, orhave little effect on fear extinction depending on dose and timing. Human PTSDstudies combining ketamine with trauma-focused psychotherapy are promising butremain preliminary and heterogeneous.

Conservative teaching statement: ketamine may alter theconditions under which traumatic memories are updated, but we do not yet knowprecisely when it facilitates reconsolidation, extinction, both, or neither.

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8.Why ketamine may help aperson who already dissociates

At first glance, using a dissociative medicine for a personwith trauma-related dissociation appears paradoxical. The key is that the twoforms of dissociation may have different functions.

A traumatized nervous system may learn:

intense emotion → disappear.

Over time, the threshold may fall:

moderate emotion → disappear.

When therapy approaches traumatic material, freeze,numbness, derealization, or disconnection may occur before sufficientsimultaneous contact with memory, emotion, body, present safety, andrelationship can develop.

Carefully dosed relational KAP may sometimes create distancewithout complete defensive disconnection: “The memory is there, but it is notconsuming me.”

“Traumatic dissociation removes the person from theexperience. Ketamine can sometimes remove the experience from its usualstranglehold on the person.”

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9 Structural dissociationand integration

Structural dissociation models describe compartmentalizationamong everyday functioning and trauma/defense-related states. Regardless ofwhether one adopts the full model, the clinically useful idea is that traumacan segregate memory, affect, identity, bodily state, and defensive action.

Good therapy increases the capacity for previouslysegregated states to coexist within one field of awareness without one statecompletely taking over or disappearing.

Relational KAP-the altered state may create conditions inwhich previously mutually exclusive self-states can become simultaneouslyaccessible and potentially integrated through psychotherapy. Ketamine in arelational container can connect and integrate parts of the brain from deepersubcortical circuits , amgydala, thalamic cortical circuits and amongst partsof the cortex-creating conditions and capacity for integration that otherwiseis difficult to achieve especially when subcortical-cortical circuits are not incommunication

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10 PAG, superior colliculus,and orientation

The PAG participates in organizing defensive responses andpain modulation and is implicated in freezing, escape, and survival-relatedbehavior. Dissociative PTSD research also points toward altered connectivityinvolving prefrontal, amygdala, and brainstem defensive systems.

The superior colliculus participates in rapid orientingtoward salient sensory stimuli. DBR proposes that attachment and shock traumamay become linked to very early orienting and defensive sequences.

In relational KAP, opening the eyes and locating thetherapist may involve a primitive sequence:

orient → recognize another human → assess → contact →settle.

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11 Interoception, insula,and changing the meaning of sensation

The insula integrates bodily state, salience, and subjectiveemotional experience. Trauma can involve either hypervigilance toward bodilydanger or profound disconnection from bodily sensation.

Ketamine alters insular and salience-networkactivity/connectivity in ways that vary across studies. Clinically, patientsmay sometimes encounter familiar sensations with unfamiliar meaning:
pressure is no longer catastrophe;
shaking is no longer “I am dying”;
vulnerability is no longer synonymous with helplessness.

An SE-informed therapist is not necessarily trying toeliminate sensation. The new learning may be: “I can experience this sensation,remain oriented, stay connected, and discover what happens next.”

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12 Amygdala and hippocampus: threat in context

It is overly simplistic to say ketamine “turns down theamygdala.” PTSD studies suggest ketamine can alter relationships amongprefrontal, amygdala, and hippocampal systems. A more defensible formulation isthat ketamine may change how threat processing interacts with contextual memoryand cortical regulation.

The hippocampal bridge is especially useful clinically.Trauma can make an organism respond as though the past is present. Orientation- seeing the room, hearing the therapist, sensing support, noticing one'scurrent age and location - can be conceptualized as supportingcontextualization.

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13 Social safety isbiological information

Interpersonal safety is not reducible to a single “ventralvagal” pathway. Social experience recruits distributed cortical, limbic,striatal, hypothalamic, autonomic, and neuromodulatory systems..

The important principle is simpler: the nervous systemtreats the behavior and presence of another human as biological input.

Therefore, in relational KAP, the therapist may be more thanan observer of the pharmacological intervention. The therapist can become partof the information the brain is learning from.

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14. Why “doing therapy tosomeone on ketamine” can miss the point

Relational KAP may work less through interpretation and morethrough presence, contingency, attunement, permission, choice, nonintrusion,orientation, witnessing, and repair.

These experiences directly contradict many relational-traumapredictions. Repeated demands to explain, perform, interpret, or “go deeper”can inadvertently recruit familiar compliance or performance defenses.

Sometimes the most potent intervention is simply an attuned,non-demanding signal: “I am here.”

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15. A functional definitionof integration

Integration is not simply remembering everything, catharsis,or maximizing emotional intensity.
Increasing the nervous system's capacity to hold sensation, affect, memory,self-awareness, temporal context, agency, and relationship simultaneouslywithout needing to fragment experience.

This formulation makes the potential role of relational KAPintuitive: the goal is not maximal alteration, but sufficient flexibility topermit more simultaneous experience and new learning.

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16. Trauma-driven vs ketamine-induced dissociation

Trauma driven is defensive in nature vs. Ketamine is pharmacological with defined beginning and end, agency and inherently built in capacity

17 Why relationalcontainment matters especially in dissociative PTSD

Ketamine can also produce disorientation, fear, loss ofagency, perceptual distortion, unusual bodily experiences, and ego dissolution.For people with trauma involving loss of control, immobility, medicalprocedures, powerlessness, intrusion, or abandonment, these effects canreproduce rather than repair traumatic dynamics.

Therefore dose, pace, touch, silence, proximity, permission, and thepreservation of choice all have relational meaning. The medicine does notautomatically generate safety. Set, setting, preparation, consent, andmoment-to-moment attunement help determine whether altered consciousnessbecomes exploration or another experience of helplessness.

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18. Proposed circuit modelof relational KAP for dissociative PTSD

1.      Ketamine → NMDA-related cortical effects /altered excitation-inhibition

2.      ↑ glutamatergic throughput through AMPA-relatedsignaling

3.      BDNF-TrkB / mTOR-related plasticity pathways andsynaptic remodeling

4.      Acute reorganization of DMN, salience,executive, insular, hippocampal, and thalamocortical dynamics

5.      Potential loosening of rigid self/threatpredictions

6.      Trauma material and defensive responses becomeaccessible

7.      SC / LC / PAG / amygdala / insula-relatedorienting, alarm, threat, body, and defensive processes may emerge

8.      Therapist supports orientation + agency +titration + relationship

9.      Hippocampal/context systems: “This is now, notthen.”

10.  Metacognitive/executive systems: “I can observethis.”

11.  Social-relational systems: “I am not alone.”

12.  Embodied learning: “I can survive and remainpresent with this sensation.”

13.  Prediction error → possible extinction /reconsolidation / new relational learning

14.  Post-session plasticity + integration →consolidation

15.  Potential reduction in automatic defensivedissociation when the network is activated again

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9 Putting DBR, SE,attachment, parts, memory science, and ketamine on one map

DBR: Whathappened in the organism before fully elaborated emotion?

Somatic Experiencing:What autonomic, sensory, orienting, and defensive process is unfolding now?

Attachment therapy: Whatdoes this nervous system expect will happen between us?

Parts/state work: Whichstate-dependent organization of self is active, and can multiple statescoexist?

Memoryreconsolidation / inhibitory learning: What old prediction is beingactivated, and what new experience violates it?

Ketamineneurobiology: What changes when ordinary network organization becomestemporarily less rigid while plasticity-related processes increase?

Relational KAP: Canthese processes be held together in a safe, embodied, relational learningenvironment?

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20 Hypothesis andDiscussion Points

·       Trauma-driven dissociation is usually adefensive disconnection from experience because experience has becomeintolerable. Ketamine-induced dissociation is a temporary pharmacologicloosening of the brain's ordinary integration of self, body, perception,memory, and salience.

·       Ketamine through its neuropharmacologicalmechanisms create capacity and re-connection/integration ofcortical-subcortical circuits that are usually offline in PTSD and Trauma.Allowing integration and flow of communication potentially allows forintegration of experiences that otherwise are difficult to integrate

·        Inwell-held relational KAP, that loosening may allow a person who chronicallydisconnects from experience to encounter previously intolerable experiencewhile remaining connected enough to another human being, the present moment,and an observing self.

·       When a traumatizedperson dissociates, the nervous system may be saying: “I cannot remain here andexperience this.” Ketamine can also create distance from ordinary experience,but through a different biological pathway. In a carefully held therapeutic relationship,a person may sometimes discover: “I can be far enough away from this experiencenot to be consumed by it, yet close enough to encounter it. I can remainconnected to my body, another human being, and the knowledge that I am herenow.”

If this occurs during a period of increased neural flexibility, the clinicallyimportant possibility is not simply remembering differently, but learning adifferent way of being with the memory and the felt sense of the experience.

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Michael Yasinski MD

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