As explored in some previous resources, ketamine is a unique medicine as it can provide specific biological and phenomenological experiences that lead to its classification as both a dissociative anesthetic and a psychedelic medicine.
Originally synthesized and used in the medical field as a surgical anesthetic, ketamine’s dissociative properties were and remain highly useful in surgical procedures requiring anesthesia. Through ongoing study, an ancillary benefit was noticed — individuals who received ketamine were reporting marked improvements in mental health conditions such as depression and anxiety. This opened a new field of study, which continues to this day, and brought about the introduction of the off-label prescription of ketamine for certain mental health conditions.
In the context of mental health treatment, the dissociative effects of ketamine can be beneficial from both a neurobiological and phenomenological perspective. But what exactly is the process of dissociation? This article explores the definition, use-cases, benefits, risks, and existing classifications of dissociation and its role in the greater context of mental health conditions and treatment.
Ketamine: Psychedelic Medicine or Dissociative Anesthetic?
There is discussion in clinical and psychedelic circles about the appropriate classification of ketamine in context of psychedelic therapy. It was originally synthesized as a dissociative anesthetic, but it’s now applied as a psychedelic medicine for mental health treatment. What should one make of either of these distinctions?
The classification of ketamine as a dissociative anesthetic is clear and direct. The medical introduction of ketamine was for anesthesia, and it has been used in this way for several decades. All clinics, practitioners, health organizations, and regulatory bodies such as the Food and Drug Administration (FDA) recognize ketamine as a dissociative anesthetic.
It is ketamine’s designation as a psychedelic compound that brings about more discussion. There is a clear argument as to why ketamine can be considered a psychedelic, especially as it’s already an established medicine used in psychedelic therapy contexts.
The Neurobiological Argument
One of the common counterpoints against ketamine’s classification as a psychedelic is that ketamine does not affect the brain in the same way “classical” psychedelic medicines (LSD, psilocybin, DMT) do.
These classical psychedelics are commonly 5-HT2A/B receptor agonists, binding to a specific receptor site in the brain, working on the serotonergic system, and inducing the hallmarks of a psychedelic experience in that manner.
Ketamine does not share the same mechanism of action. It works on N-methyl-D-aspartate (NMDA) receptors and influences the glutamate system. On this neurobiological difference alone, some individuals are inclined to dismiss ketamine’s designation as a psychedelic medicine.
However, when considering the fullness of the psychedelic experience, and when discussing what commonly defines the hallmarks of a psychedelic experience — one that is largely defined by its subjective, phenomenological markers, it seems odd to have the exclusion criteria be solely based on the neurobiological mechanisms.
The Subjective / Phenomenological Argument
If you look at the hallmark characteristics of a psychedelic experience — feelings of unity, self-transcendence, distortion of space/time, novel ways of thinking/feeling/experience — they are well within the scope of a ketamine experience. Many clients report having experiences of visions, novel sensations, out-of-body experiences, and other sensations.
If you use this subjective/phenomenological description, ketamine can fit the definition of a psychedelic medicine for use in psychedelic therapy.
What does “Dissociation” Mean?
Dissociation is a mental process where a person disconnects from their thoughts, feelings, memories, or sense of identity.
There may be an experience of a “distance” between the sense of self, the thoughts that are arising in awareness, the person they see in memories, or from the physical sensations and presence of the individual's body.
Separately, there are also dissociative disorders as designated a mental health condition in the DSM, as opposed to a subjective state induced by certain experiences and/or compounds. Dissociative disorders include dissociative amnesia, dissociative fugue, depersonalisation disorder, and dissociative identity disorder. This will be addressed further below.
There are some hallmark subjective experiences that can help determine if dissociation is occurring, and the level of dissociation that has occurred. Some of these phenomenological markers include:
- Feeling like things are in slow motion or seem unreal
- Feeling separated from reality
- Feeling as if looking at things from outside the body
- Feeling like you are a spectator or like you are observed
- Objects looking different
- Colors seeming duller or brighter than usual
- Time speeding up or slowing down
- Seeing things through a fog or having tunnel vision
- Losing track of time or what is happening in the environment
- Feeling as though your body has changed
For an individual who has never had an experience of disconnection like this, the experiences can be challenging at first. But they can also be beneficial, giving individuals a momentary glimpse at the functioning of their own psyche and thought patterns, a break from strenuous emotions or trauma, or even a sense of self-transcendence —a feeling of being more than, or out of, the confines of one's individual body.
What is a “Dissociative”?
Given the aforementioned definition of dissociation, a dissociative is any compound, medicine, or experience that can induce dissociation in an individual, reliably, and according to the subjective phenomena listed above. This state is referred to as dissociative anesthesia, a trance-like state providing pain relief, sedation, and amnesia.
To measure the state of dissociation and the level of dissociation that was experienced, clinicians and therapists will use a scale to validate and measure the levels of these experiences.
The Clinician-Administered Dissociative State Scale (CADSS) is a tool that clinicians use to measure the degree of dissociation during ketamine infusions. By ranking the extent to which a symptom occurs, the CADSS can assess the psychoactive effects of ketamine. The higher the CADSS score, the more dissociative symptoms a patient is experiencing, and vice versa.
Dissociative drugs can produce visual and auditory distortions and a sense of floating and dissociation (feeling detached from reality) in users. Ketamine is the most prominent dissociative used across medical and clinical environments, though other compounds that induce dissociation do exist.
Part of the promise and potential of ketamine treatment is that at certain levels and dosages for individuals, ketamine induces a dissociated state while the individual maintains conscious awareness. By maintaining consciousness throughout the experience, the individual has the opportunity to raise particular insights, and experience new or powerful sensations or emotions, all of which can be helpful to the individual and the clinical team when working through anxiety, depression, or other mental health conditions.
Benefits of Medically Induced Dissociation
While some studies have concluded that patients who experience more intense dissociation symptoms during ketamine infusions can have greater or more sustained antidepressant benefits, most have found no correlation between the degree of dissociative symptoms and antidepressant effects.
This references only the neurobiological effects of dissociation. Though even those results are promising, as they indicate the potential of the antidepressant effect of the act of dissociation as induced by a dissociative such as ketamine. The potential of using a dissociative to experience some level of acute and possibly sustained antidepressant effect is promising. Much of the potential of dissociation lies in the work that can be done by the individual and care team during and after the dissociative experience.
In many mental health conditions, recurring, intense, or habitual negative thought patterns are common. No matter the thoughts —anxious, depressive, or self-negative — the persistence of these ideas, thoughts, and stories often cause clients a level of discomfort. The persistence makes them more likely to continue on and become habitual ways of being.
With a dissociative experience, the individual has the opportunity to create some distance between the thoughts, emotions, feelings, and themselves. With this ”subjective breathing room,” the individual is given the opportunity —perhaps for the first time— to take some space and time to collect themselves. This space allows an individual to look directly at these behavioral patterns, and then return to their lived experience to tackle them with new insights or ways of viewing these things.
Dissociation can also include more positive effects that for someone working with anxious or depressive tendencies can be a catalyst for positive change moving forward. This can include feelings of connection, the sense of being more than just your body, access to new or heightened emotions/insights/lived experiences,.
When the two main potential benefits —the neurobiological antidepressant effects, and the subjective experiential distancing— are combined, it creates a conducive environment for the integration and processing work to begin alongside the individual’s care team. With renewed energy, insights, or emotions, individuals can begin taking the steps to create positive and long-lasting changes in their lives. Especially in areas that were potentially catalyzed, accelerated, or augmented by the dissociative experience itself.
Is Dissociation a Bad Thing?
Dissociation itself is also noted as a symptom related to other mental health conditions. In the aftermath of traumatic events, or chronic exposure to unsafe or threatening situations, the body and psyche as a defensive mechanism may induce an acute, episodic, or sustained state of dissociation to protect the individual from the emotions or traumatic feelings that arise.
The defensive mechanisms of the mind and body may induce dissociation as a protective force. The individual may seem withdrawn, disconnected from their body, aloof or uncertain, and any of the defining dissociative symptoms mentioned at the beginning of this article.
Separately, there are dissociative disorders, diagnosable conditions as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5). one that is brought about as a defensive protection from the individuals mind and body. Dissociative disorders are mental health conditions, while dissociation is a subjective feature of some medicines and compounds. As is typical within the psychedelic therapy space, the context, content, and nuances included in these definitions and the steps taken to move forward are important.
Using the dissociative experience, as facilitated by a care team and induced by dissociative compounds, can be a powerful and potent assistant when working through certain mental health conditions like depression and anxiety.
At the same time, dissociative disorders are also a mental health concern outside of clinical settings, and this underscores the importance of working with trained and experienced professionals when embarking on psychedelic therapy programs or individual healing journeys overall.
There is a lot of nuance, the mind and psyche are complex and dynamic forces, and working with trained professionals helps to ensure correct diagnoses, correct dosages, and correct experiences to move individuals towards healing and wholeness again.
Dissociation is a subjective and personal experience. It can be a symptom of other conditions such as major depression, and it is a subjective state that can be induced directly through dissociative compounds like ketamine.
There are a host of potential benefits that dissociation can bring about, from neurobiological antidepressant effects, to subjective reframing and novel experiences to help create long-lasting behavioural change. There are also a host of individual challenges that can emerge if someone is experiencing persistent dissociation on a daily basis — namely being disconnected from their lives, from the beauty of emotions, from the direct vitality of conscious experience.
If you, or someone you know, may be experiencing dissociation, or would like to discuss the potential of working through this together, you can get in touch with our team after taking our survey.
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This article is for informational purposes only and is not intended to be a substitute for professional medical advice. Always talk to your doctor about the risks and benefits of any treatment. If you are in a life-threatening situation, call the National Suicide Prevention Line at +1 (800) 273-8255, call 911, or go to the nearest emergency room.
Important FDA Safety Information
Ketamine is not FDA-approved for the treatment of depression or anxiety. Learn more about off-label uses here.
Side effects of ketamine treatment may include: altered sense of time, anxiety, blurred vision, diminished ability to see/hear/feel, dry mouth, elevated blood pressure or heart rate, elevated intraocular or intracranial pressure, excitability, loss of appetite, mental confusion, nausea/vomiting, nystagmus (rapid eye movements), restlessness, slurred speech, synesthesia (a mingling of the senses).
Do not proceed with ketamine treatment if any of the following apply to you:
- Allergic to ketamine
- Symptoms of psychosis or mania
- Uncontrolled high blood pressure
- CHF or other serious heart problem
- Severe breathing problem
- History of elevated intraocular or intracranial pressure
- History of hyperthyroidism
- Other serious medical illness
- Pregnant, nursing, or trying to become pregnant
Ketamine has been reported to produce issues including, but not limited to, those listed below. However, lasting adverse side-effects are rare when medical protocols are carefully followed.
While ketamine has not been shown to be physically addictive, it has been shown to cause moderate psychological dependency in some recreational users.
- In rare cases, frequent, heavy users have reported increased frequency of urination, urinary incontinence, pain urinating, passing blood in the urine, or reduced bladder size
- Ketamine may worsen problems in people with schizophrenia, severe personality disorders, or other serious mental disorders.
- Users with a personal or family history of psychosis should be cautious using any psychoactive substance, including ketamine, and discuss potential risks with your MindBloom clinician before proceeding with treatment.
- The dissociative effects of ketamine may increase patient vulnerability and the risk of accidents.
To promote positive outcomes and ensure safety, follow these ketamine treatment guidelines:
- Do not operate a vehicle (e.g., car, motorcycle, bicycle) or heavy machinery following treatment until you’ve had a full night of sleep
- Refrain from taking benzodiazepines or stimulants for 24 hours prior to treatment
- Continue to take antihypertensive medication as prescribed
- Avoid hangovers or alcohol intake
- Refrain from consuming solid foods within 3 hours prior to treatment and liquids within 1 hour prior to treatment
- Ketamine treatment should never be conducted without a monitor present to ensure your safety