Ketamine: Dissociation Quality Determines Remission

Transformative remission is inextricably linked to the quality, depth, and degree of dissociation during ketamine infusions.

Christopher trudged through the day, listless. He felt dead inside. Just couldn’t work up a care about what happened at the job interview. But practicality — the bills were piling up — drove him to go anyway.

He did his best in the interview, then got in the car to hurry home where he could retreat into his dark bedroom and sleep. He thought about death…about ways of ending his life… of making a plan that would work, before he could be interrupted. He knew he wouldn’t do it. But he’d been living with these thoughts all his life, and in the bad times it was the only way he could calm his mind and maybe fall asleep.

After months of research with studies she found online, his wife had been talking to him about ketamine treatment, and how it could not only wash away the suicidal thoughts but could help him feel good again, and find the energy to live. To care.

He wasn’t buying it. Just another antidepressant. They don’t work and never have. One more way to throw away money. A waste.

Still, she insisted, and he resigned himself to be a “guinea pig.”

How Dissociation Quality Determines Remission Lasting Power

The first two infusions were pleasant. Relaxing. Sort of “billowy.” But once each one ended he was back in the real world –, irritable, edgy, resigned. He thought to himself that surely his wife will now accept there’s nothing that will work, and leave him alone about it.

His wife, however, was determined. If ketamine could help others achieve remission, then it could help her husband.

When the doctor came in, she told him in no uncertain terms that nothing good was happening to Chris that she could see. She pressed the doctor to change something so this would not be a waste of money…and hope… Because his hope was gone. He needed success.

Increasing the Dose and Duration

The doctor agreed and increased the dose and extended the duration of the infusion to try to find that sweet spot between relaxation and overstimulation. Christopher’s “relaxing” experience was quite different this time.

Little by little, he lost his awareness of his chair, his presence in the room, and of his wife sitting nearby. He felt himself floating into another room…then another place…and then he lost awareness of himself and just let his mind float, and fly, and feel freedom. He didn’t care what was happening. Christopher thoroughly enjoyed the respite and relief of this vacation from his pain.

After his treatment ended, Chris felt a tinge of renewal. Of refreshing. Just a tinge…but it was unmistakable from the previous infusions where he soon returned to the same despair.

Now I get it, he thought. I see where this is trying to go. He set about googling and reading to find out how to prepare himself for the next infusion, to give it its best chance. He also picked back up a low stress hobby he’d enjoyed in the past and found he was enjoying it again. Did he feel happy?  No. But there was something different.

Just a tinge of hope.

Christopher talked to the doctor about the first two infusions, who suggested that they keep doing infusions for awhile to make up for the lost ones. The doctor was willing to see where it took Chris, since he admitted he was learning what ketamine could do, too…

The 4th, 5th, 6th, 7th, and 8th infusions each enfolded Christopher in a deeper, more intense, and longer lasting dissociative experience then the one before.

By the end of the 8th infusion and for the weeks that followed, Christopher discovered life with a fresh new perspective.

He saw everything through more hopeful, optimistic goggles, and found more energy to create wondrous software programs in his work, enjoyed his wife like he never had before, and took up painting sunsets in a quest to truly capture the intensity of colors he saw.

Christopher has been enjoying his life and living it with gusto for the last 13 months since his ketamine treatment. He still looks back with gratitude on that day when his wife pressed him to let the doctor raise the dose, and the transformation with ketamine began…

…

In another blog, we discussed the role dissociation plays in remission from depression symptoms.

Let’s talk more about what that dissociation can be like.

Dissociation Quality Determines Remission Power

Since this last article about dissociation was written last fall, the field of ketamine for treatment resistant depression and other psychiatric disorders has grown by leaps and bounds. You can sample some of the reasons why here, here, and here.

Physicians, researchers, pharmacologists, and biochemists are in high gear exploring, testing, adapting, and learning at such a clip it’s hard to keep up.

But with so many brilliant neuroscientists constantly studying ketamine treatment — and so many dedicated physicians learning more and applying the new information to their patients’ treatments — growth was bound to happen.

So in the six months since our last blog on dissociation, we’ve learned that the standard dose of 0.5 mg/kg of ketamine is on the low end of average in effective antidepressant treatment. In our practice, a higher dose is needed in most patients before they experience deeper dissociation and remission of their hopelessness and depressive symptoms.

We’ve also learned that by clinging to the originally tested 0.5mg/kg for the full series of six or more infusions, many patients fall short of remission. So we’ve adopted flexible dosing and adapted infusions to the individual.

Because remember, as we keep saying, in a private real-world practice (as opposed to a research laboratory) our goal is to help each patient achieve remission from their symptoms. That means we remain open-minded to those things that may help our patients reach their goals.

We do what it takes.

And we’ve just submitted a paper for peer review describing this.

How Does Dose, Rate, and Duration of the Infusion Affect Remission?

So with that in mind, we seek to administer the ketamine infusions with remission as the target goal, and therefore adapt dosage, rate, and duration of the infusion based on each patient’s response to this medicine in each infusion.

Remember… 15 years ago, remission from treatment resistant disorders was pretty much unheard of. We’re exploring this frontier to find the best results for each patient.

This is the most personalized form of medical treatment available, and it’s vital for taking a long term illness from debilitation to remission.

So let’s go a little deeper.

What is dissociation and what isn’t..?  Does it matter what happens in a patient’s brain during the infusion, as long as ketamine is infused into his or her body?  Isn’t this medicine delivered through the IV based on the person’s weight, like most medicines?

These are great questions, so let’s take them one by one. The answer to the last question is NO.

Apparently, according to some studies between 2015 and 2018, the dissociative experience is explicitly connected to reduction in depressive symptoms. Which means dissociation helps you get well.

So it turns out that just infusing the body with ketamine isn’t enough. Something more is needed. Intense dissociation gives your brain what it needs to reboot… and feel joy.

In addition, that dissociative experience is not triggered by ketamine delivered in a standard dose based on body weight. It varies between individuals and needs to be titrated according to that individual’s response.

We see this first hand, every day. We know it.

Now, as far as dissociation, it’s the sense of being detached from yourself, or your body. We’re not talking about a disorder here, but rather a sense, or feeling, that occurs during the ketamine infusion.

You may experience a lovely floaty dreamy feeling, one where it’s like you’re daydreaming and relaxed. You may feel as if waves are splashing around you, but more in a metaphorical sense. But at the same time, you’re aware you’re sitting peacefully relaxed in a chair or recliner, but you’re not focusing on that. If someone speaks to you, you can easily respond. You’re aware of yourself, but not focused on yourself.

This isn’t dissociation, though it may be leading to it.

So What IS Dissociation?

Dissociation may be hard to describe but you’ll know it when you experience it. For lack of a better term, it’s a feeling of being separate from your body or yourself while still feeling relaxed. It may seem as though you’ve left your body and are floating above it, or in another place. It’s not an unpleasant or frightening feeling, but rather a relaxed sense of freedom… and it’s often accompanied by billowing relief.

In other cases, it may be a deep dive into your “inner workings,” your outlook and motives, your biases and self-imposed limitations… all in a flexible atmosphere where you can change the attitudes you want to change.

In still others, it may be more spiritual in nature, a transformative, almost metaphysical experience, focused on your spiritual self.

Remember, this is your brain. And your experience during dissociation will be uniquely yours.

No matter what the format of your dissociation, the importance of this is that it’s a direct sign that ketamine is at work in that moment repairing the signaling structures in your brain and all the damage that stress and depression have done. It doesn’t all happen at once, but the process does start right then.

For this reason, when you feel that “floating above your body” feeling or however it happens with you, we know it’s important that what you’re experiencing is sustained awhile.

This crucial time sees the repair work initiated and carried out and you may begin to feel a bit better within the hour. You may even find that you feel better and better through the next day and the day after that.

When your brain is functioning at full capacity, all the neurons are happily buzzing along carrying billions of signals all around your brain as you think about things, feel emotions, make decisions, sort through offenses, and figure out solutions.

Each neuron brandishes branches of buds that burst into connections with other neurons forming a dense and complex network.

You think the internet is complex? Ha! It’s a child’s toy compared to this. Every thought you form requires signals dashing around your brain pulling memory and feelings from the hippocampus and amygdala, managing impulses in the prefrontal cortex, and around and around it goes until your thought is formed.

And the beauty of it is that it can do that at the speed of light, while you memorize volumes of scientific theory, write a speech for a women’s conference, and compose music for your recital.

But when trauma or overwhelming stressors shove you into depression,  those signaling pathways slow down, break apart, and thin out. Then, you find yourself left with something about as sophisticated as a string suspended between two tin cans. Remember those “telephones” when you were a child? Primitive. Impaired. Ineffective.

(You can hear some buzzing when someone talks to you but it’s hard to make sense of it. You can say something simple and try to make it heard by your friend in the tree house, but it won’t likely be the Gettysburg address.)

Your energy to try drains away. Your ability to think complex thoughts seems to all but disappear. The ability to perform becomes so “last year.”

You need a way to overcome this, but all the things they tell you to do just don’t help much at all.

It all seems futile, and you’re too weighed down to even try much anymore.

And then you hear about ketamine treatment and you go for your first infusion… (as in…how soon can you see me??)

What Happens During Your Ketamine Treatment

There is something significant that happened when Chris moved past the relaxed floaty feeling and advanced to “another room then another place…” and “let his mind float, and fly, and feel freedom.”  That sensation is the outward signal that ketamine is repairing and restoring. 

It triggers massive production of turbo-boosted brain-derived-neurotrophic-factor (BDNF) which causes the synapses to explode into branching and proliferating connections that spread across the brain in a sort of fast motion animation.

It happens at high speed and results in these sensations and impressions like floating then flying and swirling around.

Dissociation quality determines remission durability. And you want your remission to last and to be resilient, right? So be sure your doctor helps you experience intense and extended dissociation.

It seems possible – even likely – that some of those who are receiving the flat dosage of 0.5mg/kg without titration aren’t achieving sustained remission… Could it be this is why some of those are needing to return for maintenance doses every month or two?

We have studies that show that dosing below 0.5mg/kg doesn’t work well to decrease depression symptoms. And it might be that this dose decreases depression symptoms, but is not enough to bring on actual remission.

Is there a magic dose that always results in remission for everyone? Unfortunately, no …(wouldn’t that make things simpler?)

Is it possible that by titrating the dose, raising it a bit higher — according to a patient’s response — it could help a patient achieve remission? Well, it’s safe to say his or her chances are much better. What do you think? I’d love to read your comments!

With the new esketamine intranasal spray approved by the FDA, and with ketamine treatment becoming increasingly effective as we learn what it’s teaching us, hope is growing. People are getting well.

We’re learning. All of us are learning together. The field of ketamine for psychiatric disorders didn’t come with a manual, but we’re reading, and comparing notes, exchanging experiences, and watching our patients respond. And the more we learn, the more people get well.

Options are improving.

Watch for word from your own insurance company in coming months about their stance with esketamine. We expect to see more and more insurers get on board with esketamine intranasal spray.

But if you want treatment now, and you seriously seek remission, call us. And let’s work together to help you experience full and deep dissociation to the end that you may achieve remission. So you can build your life and your relationships. And work toward your dreams.

To the joy of life as your best self,