At some point at the beginning of the dissociative experience I became distracted by a sensation on my cheek which my brain translated as an itch. My mind returned to my body so that I could lift my right hand to my face and scratch it. My arm seemed to move very slowly and it felt like I didn't have full articulation in either my elbow or wrist. To make this strange state even weirder, my mind told me that my arm from shoulder to hand was made of inflexible blocks of wood. When I touch my cheek to scratch, my fingers and cheek had the texture and firmness of wood. As with previous distortions and hallucinations, I accepted this by thinking, as a matter of interest, that becoming a piece of wood might be a unique perspective.
Using my breaths to guide mind back into my body, I noticed the music playing through my earbuds. My breathing was gentle and my pulse a steady pounding that I both heard and felt.
I spent some time trying to evoke that uncomfortable “twang” feeling in an attempt to explore it but was unable to.
Mental Imagery – My Inner Self
With mind and body back together, I felt like I ought to try and get some therapeutic work done through self-exploration by traveling deep within myself. A simple representation of a door appeared before me and I moved towards it. As I reached the door, it opened revealing a hatch and then another portal after that, hundreds of layers represented by different types of portals flung open until finally I reached what might have been a representation of my innermost self. It's closed and was covered by an object. I felt a sort of warning, a sense of caution that arrests my forward movement. I tried to peer around the perimeter but the object covering it sprouted wings that shielded all four edges of the portal. I felt I could transgress this barrier but then a very clear voice inside me said, “Don't”.
That warning sounded firm and final and I will confide, it caused me to completely chicken out! Bok bok B'gok!
The wooden god dissociative experience makes me wonder if the Ketamine stimulated the part of the brain which under imaging, shows activity during a religious experience. In retrospect it doesn't seem as much of a religious experience as a near-death one. I didn't receive any great news for us all or a message from dead loved ones or some insights about the infinite known to cultures around the world as That Which Is. No prophecies, either. So if it was a religious experience, I would rate as a pretty poor one in comparison to other experiences of my own and those told to me.
That threshold I came upon where I had a choice to remain or quit being connected to everyone definitely felt like a very real choice to live or die. I choose to regard my decision as an affirmation of my desire to live in spite of the struggles and difficulties of living with mental illness. Similar to suicidal ideation, it's a sort of comfort to have the choice. I wonder what it'd be like if I opted to remain.
The memory of feeling every type of fear in everyone remains but it has faded. I wish I had named all the fears I felt, it might've been useful to bring up in analysis. As a concept, everyone can understand that there's fear in every animal and person but it's quite another thing to have been in a state where one fancies one can feel it all. Sometimes, I'll call upon this memory when I'm in some group of people feeling anxious, self-conscious and insecure to remind myself that everyone in attendance is feeling at least a little fearful about something and this understanding assures and soothes me.
Regarding the deep introspection I sought through the portals, I have so many questions. Why was I afraid to continue, what was that voice telling me not to? Would there have been yet another door beyond what I thought was the final portal? (Years of therapy has shown me that every time I think I've come upon the final level of all my basement floors, there's yet another right below it. Always another issue beneath the one I thought was the most telling. Ha.) Is there always a “something” covering something else and is that the very definition of personal safety? Is what I perceive as covering my innermost core shielding me from harm or from scrutiny? Discussing this in therapy, I realized that in addition to wariness and fear I also felt vulnerable confronting that last layer. I'm unsure if that feeling was a genuine reaction to my introspection or due to a general feeling of vulnerability one has while conscious under anesthetic.
Outlier vitals reading: 103/68
I spoke with the doctor and his colleague about what I remembered of the experience, noting that the bump in dosage seemed to make a difference. I also met with a clinical psychologist whose practice includes Ketamine assisted psychotherapy. She was keen to know about the music I chose and it's effects on the Ketamine experience. I felt lucid and cognizant during our conversation.
In the next entry, I'll detail the sixth and final infusion of the initial protocol I received back in 2017.
Now that you know
That something's not right
Look at it carefully
In pale logic light
Don't be sorry
If you can't recognize
The errors and faults
In such a perfect disguise
Only illogics can find hidden flaws in a straight logic line
Only erratics recognize errors in patterns of a perfect design
- Erratic Patterns by Carbon Based Lifeforms
Usual pre-infusion protocol. Music playlist a mix of ambient and songs with lyrics in a language I don't understand.
About 10 minutes into infusion, I noticed the anesthetic effects – nausea and numbness – were stronger this time than the previous infusions which I attributed to the increased dosage. Once again I felt anxious and wondered how strong these sensations would get,. What to do with these anxious feelings? I never found that trying to ignore or bury anxiety was effective in dealing with it. Better to find a way in which to acknowledge it, allow it to be present and express itself but not dwell on it. I discovered a bit of mental imagery that helped me. I pictured the nurse standing at a control panel, her hand on a dial that's meant to increase or decrease dosage of the drug. She looks to me and asks, “Are you OK, is it too much?” I reply, “Unpleasant but tolerable. Continue. Give me more.” Unpleasant but tolerable becomes a sort of self-soothing mantra as the effects of the Ketamine envelope me; it acknowledges feelings without overstating them.
Sensation of Motion
About 15 minutes into the infusion I felt weightless and floating and following that, a sensation of horizontal and vertical movement. I peeked through the seam of the sleep mask to verify that my body wasn't moving but my inner ears and brain reported motion nonetheless. Reclining in the chair as I was with both feet raised, an image of laying on a pedestal or platter came to mind accompanied by a strange feeling of being “presented” to something. I felt a bit vulnerable and exposed but aided by some uplifting music, this became sort of joyful.
Dissociative Experience – Celestial Postman
For a moment I'm in that strange, in-between state of semi-consciousness where nothing exists. Then I'm outside my body, looking at my face through a small window of a rocket ship. In the same manner in which we give context to what's happening in our dreams, I knew that my destination was the heavens and that I was a sort of celestial postman, delivering messages written to God from people all over the planet – even personal messages from my attending doctor and nurse. I felt pleased, excited and a bit honored to have this mission. Looking back at it now, I wonder if how I felt is similar to how people who experience grandiose delusions must feel, it was very convincing.
The rocket launch was convincing as well. I felt the motion in my lower body and saw amazing displays of speed and light before reaching space.
In orbit around the planet was a long, carved wooden statue roughly in the shape of a person like you might see in a museum or upon a totem pole. I delivered the “mail” and wondered what it might be like to be a wooden god floating in space. An entity inside the statue replied that I'm welcome to try it for a bit - which I do, but hang on. Where would this entity go if I'm inside? The causal reply was, “I think I'll try being you for a while.” The irony wasn't lost on me.
Once inside the god statue, I lost sense of self in the experience of being connected to all lifeforms on the planet below. If you have ever had what you'd call a spiritual experience, this felt very similar. I don't remember much of what I did or felt in this state. One thing I recall vividly is feeling all the fear that exists in every living thing - all the kinds of fear that there is and the yearning to be free of it. I also felt the pressure of a billion people wanting me to be this and to do that for them and the strain of it all was almost unbearable. One consoling bit of knowledge was that I could leave anytime – but I could also stay there. Permanently. Deep within me I searched for what that might mean and came upon a threshold which, in order to cross, would require a very big and permanent transformation. I choose to leave the statue and just enjoy the feeling of a non-corporeal me floating in space.
Mental Imagery – Tectonic Plates Slip/Strike
I observed two circles positioned such that their edges touched. Like with the other mental images from previous infusion experiences, as I observed them my subconscious would seem to attribute a label and some meaning to what I was “seeing”. The circles became three-dimensional wheels of stone and they spun slowly inward. Where the wheels touched, sparks and bits of stone were ejected. As I contemplated the image, the wheels morphed until they resembled large land masses in turbulent, undulating motion, violently clashing against each other as if driven by an earthquake.
What this seemed to represent to me were periods of my working career. at times I worked in advocacy or volunteered and other times I worked exclusively in the private, corporate sector. I focused my attention on the boundary/fault line of the two masses and began to wonder: did they horizontally grind against each other? Did one mass thrust above another causing a subduction zone? Did they ever move apart?
Reflecting upon this later, I understand this as a representation of two parts of my self that are always at-odds: the ambitious, ego-driven me that craves status, recognition and oh yeah that big money and it's opposite, the part of me that gains fulfillment from helping others, from teaching and is driven by what remains of my idealism to improve just that tiny bit of this stinky world I move in.
I was jobless at the time and it left me to ponder if I had favored one aspect of my career at the expense of the other and whether I was I happy with my decisions.
At various times during the infusion, I used the mindfulness technique of turning attention to one's breath. This was an anchor and it proved useful. It provided a time-out from the trip during which I could ask, “what am I feeling, what thoughts are going on right now? The answers to that I would later jot down in my journal.
At some point during the infusion I felt my empty gut's squish and rumble and a gas bubble slowly travel up into my throat. Just for a moment, this felt uncomfortably and alarmingly alien but then I recognized it was just hunger. I can understand how someone who's experiencing disassociation could be frightened or worried by a routine and automatic action of the body.
About That Disturbing Dissociative Experience
If you read personal stories of dissociative experiences from Ketamine or something else, you'll find among them some truly horrifying tales. There are similarities in these stories, such as the feeling of helplessness you might feel in a nightmare.
My bad experience was worse than any I previously had on hallucinogenic drugs - but I'm okay with it. Some of the take-aways yielded great material for my therapy sessions! Also, I use it to establish a bar for my distress tolerance whenever I feel like I can't endure a difficult emotion.
That dark place I went has influenced my understanding of the quote from Star Wars I hung atop this entry. I think I now believe that the things I fear the most are deep inside me rather than in the external world. Those things give me the creeping willies and I do take them with me, everywhere.
My next entry will detail my fifth Ketamine infusion which I received the next day. The doc again increases my dose. During this infusion, I have a dissociative religious/near-death experience plus I drill into the floor of the Cellar of Me, down to sub-basements 1, 2, 3 and on until I arrive at what appears to be the core. After enduring the mortal pain of being a stain, do I really have it in me to go down there? Alone?
Yoda points, "That place… is strong with the dark side of the Force. A domain of evil it is. In you must go."
"What's in there?" asks Luke, warily
"Only what you take with you."
- Star Wars: Episode V The Empire Strikes Back
If Hollywood's taught me anything it's that if you see a door slowly creaking open or a strange gap between trees in a misty forest or a dark and creepy-looking cave - you don't go through! Right? On the other side of that entrance there's a heaping pile of dumbshits' bodies, that much we can be sure of. Nevertheless, in literature and film there's always a guy who tells everyone to wait where they are while he volunteers to be the next corpse.
Apparently I'm that guy.
I added more tracks conducive to contemplation and arranged them so that they should play during the time I expected the drug to be at it's peak. With this new playlist I sought to achieve some balance between succumbing to the infusion experience (allowing myself to be “a passenger”) and practicing mindfulness with a view towards doing some good work (therapeutically) on myself. I also added a 6 minute “sadness bomb” - a song that evoked such feelings to promote exploring sadness, pain, longing and loneliness during infusion. I wanted to make the acquaintance of whatever I kept deep inside me in the sub-basement below the cellar. The notion sounded both very interesting and stupidly bad and I vacillated most of the evening but curiosity prevailed.
As previously confided, I'm that foolish guy investigating the creepy door
The psychiatrist who administered my Ketamine treatments asked me how I felt about increasing the dosage. The doctor explained that he'd observed better results at doses that neared the 1mg/kg limit, which is the procedural (surgical) anesthetic dose of Ketamine meant to cause unconsciousness. For the previous infusions, I'd been given the standard dose which is .5mg/kg and he was suggesting around .6 which sounded fine to me.
I describe the anesthesia while conscious experience as feeling like I'm slowly being cocooned in cling wrap. Tactile sensation gradually fades, limbs soon feel weighted down until any movement is laborious and slow. I can also detect a faint plastic-like smell which I believe may be a sort of sensory memory from past surgical procedures. Ascribe it to suggestion perhaps, I thought I could feel the higher dose in the somatic effects of Ketamine.
As the Ketamine effects became more intense, I noticed a new uncomfortable sensation that's very tough to describe. It felt like a cold, steel wire was slowly being pulled through the inside of my body until it was taught, then given a vigorous pluck causing it vibrate which resulted in a sickening sensation. The sensation quickly faded. At first I thought it might be the onset of vertigo but a quick peek in the gap of my sleep mask showed the room wasn't spinning. When the feeling returned several times, I gave it a label: the “Twang”.
An image flickered in my mind whenever this Twang feeling arose. It appeared as a dark smudge – or maybe like a skid mark from a tire on a road. When I focused my attention, it became clearer but the sensation of that wire being dragged inside of me also grew stronger. To be sure, that was a disincentive to further investigation and yet... if I could just hold the image in mind, call it forward into clarity perhaps I – yes, I can pass through it.
Dissociative Experience – I Am A Stain
I don't see
I don't feel
Like every little moron I think nothing's real
So please relax
Take the pain
Laugh out loud when you forget your name
Good doesn't live and there's no evil here
Only this great power we misunderstand
- “Poledo”, Dinosaur Jr.
I melted. Once liquefied, I poured into this smudge image that my mind curiously labeled a stain and I became that: some ugly blemish on an otherwise evenly painted wall. I stared mutely out at the world watching people pass. At first, I was just an unnoticed smudge, nameless and emptied of all identity and memory but for the faintest inkling of once having been something more. Meaningless hollow minutes passed until someone paused, stooped over and took notice of me. The expression on his face twisted in displeasure and disgust and he tried rubbing me out. I wanted to call out to him, to make him aware that I am... but I had no voice with which to do so. Eventually, he sighed, discontinued wiping me away and instead, dragged a piece of furniture over to conceal me and my world fell into darkness.
Then it's light again and I could see another room. I'm still a stain but now I'm on the upholstery of a chair, I still feel hollow inside. When I'm noticed by someone, I'm regarded with displeasure, greeted with disagreeable expressions of annoyance, rejection and it filled the emptiness in me with feelings of being unattractive, unwanted, hated. Again, I tried to cry out, perhaps move a little but my brain “told” me - with complete conviction - that I had no limbs, no throat to carry a voice. I felt so utterly vulnerable and helpless, so hopelessly alone while absorbing every negative emotion emitted from the faces of those who passed by.
Eventually, every living person in the world passed me and shared a look of contempt or stole a quick scornful glance. Especially hurtful were the looks from people I knew. So I began to loathe my existence. The scenes changed, my location moved but my bleak solitude and pain was constant. There's nothing to mark the passage of time when you are a stain. I had a virtual eternity to spend as witness to the self-hating bits I harbor inside me, which now bubbled up from the rank muck of my mind, filling the hollowness.
At the end this experience, the Observer in me inquired inward what was the point of it all and the inner dialog answered something like, “So, you're a stain. It sucks. Feel it fully. And remember to share this, for someone else may understand it - as now you do.”
And I have no idea what that means.
After three Ketamine infusions, what if any improvements to my condition did I notice? To answer that I'll begin with a recap of where I was before treatment.
My baseline emotional state for longer than a year featured many MDD symptoms, such as Anhedonia (loss of pleasure in anything), an acute loss of purpose, despair from lack of therapeutic response to drug treatments and pessimism for my future. I was alive but I wasn't living. The only distinction I drew from experiences was the tolerable from the intolerable and during any social obligation, my goal was to just maintain until it's over. Though there were few obligations I had left. I wasn't working, having been fired from my job a year before and I had no significant other, having put an end to a 3 year relationship in the midst of our couples therapy session (girlfriend: jaw-drop; therapist: jaw-drop; me: wondering if I could somehow melt into the sofa).
Stripped of these obligations, I didn't feel liberated at all. I felt like a ghost of my former self returning to the same activities, coping mechanisms and the same problem behaviors that once supplied some meager nourishment to my troubled existence. They no longer gave me any relief or satisfaction yet still I "haunted" them, I guess because these are habits of the brain.
After three treatments something changed. Anhedonia dissolved. Words were pouring out of me and because I had begun a journal there was someplace for them to go. Suddenly I'm interested in searching for unfamiliar music to assist in the creation of new neuronal pathways. Suddenly there is hope. Experiencing excitement after feeling nothing for so long resembled hypomania and it's a wonder I got any sleep. Was I feeling like Bradley Cooper's character in the TV show Limitless? Nah, not really. Only in the sense that I'd begun to see there were possibilities for me that didn't seem to exist before.
Is Functionality Relief?
Yes, it is. The Ketamine Advocacy Network informed me that I shouldn't expect mood elevation so soon after beginning treatment, rather I might notice an increase in “functionality” – meaning, the ability to do stuff. I did notice what seemed like a larger reservoir of energy to draw on for activities. Self-cares, chores were no longer arduous struggles requiring mental energy to fight off impairing, negative thoughts. I felt motivated to set aside time for physical and mental exercise (meditation). I wondered if I should attribute this uptick in functionality to Ketamine therapy or was I was merely convincing myself that it was? You're probably familiar with the placebo effect and other reactivity influencing phenomena(1), anyone who's been on countless medications has experienced it for a week, maybe two. I decided I didn't have to answer that question but instead, just decide how use the functionality for however long it would last.
Improvement in therapy
Like any antidepressant, Ketamine alone isn't enough to tackle major depression. Post-infusion, my time spent in therapy sessions seemed more productive. I felt I could concentrate and participate which resulted in a better grasp of the concepts and how I could apply them. There were some moments of realization, such as how negative thoughts had been left alone to define me for so long.
Are The Side-effects Of Ketamine Therapeutic?
I'm asking if the euphoric, analgesic, anesthetic and dissociative effects have therapeutic value. I spent a lot of time wondering about this and I have a lot to say about the euphoric side-effect, as you'll see.
The euphoria felt like a vacation from my symptoms – especially anhedonia. Only a 40 minute vacation and a drug-induced one at that but I can't complain. I believe that going on an actual vacation someplace can help alleviate mild depression but for treatment resistant major depression, where symptoms can't be managed, it's near impossible to plan a trip let alone enjoy time away. A lot of people just do not understand this concept: depression is the demon shadow that goes with you everywhere, it's not something you decide to pack. The last actual vacation I went on was for two weeks and it was a disaster.
A 40 minute break from symptoms felt nice but I also believe it was therapeutic. Why? Because I'd forgotten what joy, pleasure or relaxation felt like until they pumped 50mg of Ketamine into my vein. Most mental health professionals push back on that, pointing out how the drug-experienced euphoria of Ketamine is a dangerous path to addiction or at best, a false hope for patients. Well, they can go suck it.
Why'd I write that? Because unremitting anhedonia is life-threatening. No matter what activity I forced myself into, I was checking the time at regular intervals so as to know when I could finally go home and be alone. Anhedonia was binge-watching TV while at the same time playing a game on my phone - not for entertainment but as a desperate distraction from suicidal thoughts. Self-gratifying activities like sex or masturbation were just chores that yield nothing but more frustration and self-hatred.
That is anhedonia. I hope you're feeling me.
Mental health professionals do grasp this intellectually but most don't get it emotionally so for those finger wagging Higher Minds, I prepared this rant: spare me the methodological purity sourced from your good conscience, your professional training, your best intentions and use your finger to plug your mouth-hole closed before it dispenses any more saccharine slogans. If there's no risk of physical dependency, a chemical vacation can be therapeutic for severely depressed psychiatric patients experiencing anhedonia. Yeah, I said it. Blow me away with your Straw Man sliding down a Slippery Slope argument(2).
Right. Now, what about the analgesic and anesthetic effects? They may help one to sink into the experience, especially patients who endure chronic pain daily. The floaty feeling can be pleasant. It would nice if the anesthesia element relieved anxiety but it doesn't, it's only a body sedative .The numbness adds an immobilizing quality to infusion which I don't particularly enjoy, it makes me feel sickly numb. Anxiety about Ketamine infusion is a thing, lots of patients are justifiably frightened of losing control to a drug. I'm told some patients get a dose of the sedative Versed (Midazolam) if they present with severe panic disorder.
Is there therapeutic value in the dissociative effects of Ketamine? From my experiences, I think there is. I've asked Psychiatrists about it. They wonder about the relationship and there's actual research going on to try and determine what - if any - relationship exists between dissociation and the antidepressant effects of Ketamine. I'm interested in exploring the question but that conversation belongs in it's own entry
In the next entry I'll detail my fourth Ketamine infusion, when my soaring confidence airplane got grounded and I had a “bad trip” - a scary, disturbing and revealing dissociative experience. While from another visualization, I drew some insight about why I felt so unfulfilled working in my previous jobs
Dissociative Experience – Buildings Of My Mind
Another visualization of structures, this time of various sizes and shapes. They're drawn in orange light and fill my view. Each structure resembles a building, differently sized and shaped. Intuitively, I know these contain information about all my experiences across my lifetime. I wonder if I can enter them and if so, would they have rooms that I can explore? What might each contain? The image disappears leaving me with the feeling that I caught a glimpse of a “map” of myself or perhaps, my brain.
Outlier vitals reading: 108/71 which is low for me at rest but not as low as when I'm experiencing orthostatic hypotension.
When the infusion ended, I still remembered the "towers" metaphor and reached for my phone. I began writing an email message to a friend of many years, someone I'd asked to stop contacting me due to my severe depressed state – it was just too hard to maintain the relationship. The message read something like Heym mkp-los kabip ned as I was still too intoxicated to type anything legible and nope, I didn't send it.
When I visited my therapist later that week I shared these experiences and realizations. The "towers" experience remains a touchstone I return to whenever I catch myself doing some complicated mental calculus to determine if I want to abandon isolation to join others for some activity. As for the buildings of my mind, my therapist seemed to recognize this and offered me Hypnotherapy as a method by which I could actually explore the buildings. I also began keeping a daily mood log in addition to journaling my Ketamine experiences.
As before, the mood elevation seemed to last about 3 hours after infusion, the “more restful mind” lasted about 6.
Next entry I'll take a break from describing my infusions to describe the relief experience that accompanied Ketamine infusion therapy.
"How can you stay outside?
There's a beautiful mess inside
Take a deep breath and dive
There's a beautiful mess inside and it's everywhere
So shake it yourself now deep inside
… deeper than you ever dared
… deeper than you ever dared"
- Far Far by Yael Naïm
Dissociative Experience – Human Relationships and Dependencies
Complete darkness, I was suspended weightless in the vague in-between space of near-unconsciousness. Does this seem familiar to you? It's a “waiting room” where we linger for tiny moments before a dream is “loaded”; the quasi-Sleepworld we slip inside before suddenly shaking ourselves awake to realize we've nodded off. In this twilight land there's no body, little sense of orientation.
What arose from my twilight world were numerous slender, four-sided objects resembling towers which were drawn simply in tiny golden dots of light. They filled my field of vision. I observed that each tower had windows stacked one atop the other on all sides. Some were brightly illuminated, others were completely dark. Floating over, I saw that one tower among them had mostly dark windows relative to the rest and from someplace deep within I identified with it and I called that tower “me”. I turned my attention to the other towers, what were “they”? I observed closely.
I noticed there were thin threads attached to each window of my tower spanning the space between and connecting in a giant web with each of the windows of the other towers in such a way that the dark and light windows of mine were joined to corresponding windows of the others. I silently interrogated the meaning of this.
I became aware that the other towers which I called “they” represented my friends, family, acquaintances, everyone in my life. The windows of their towers were mostly lit - except for the ones that were connected to the darkened windows of mine. I came to understand that the absence of light where these dark windows were joined meant I was no longer interacting with those individuals, all those darkened windows in my tower represented my depression and isolation. This visualization caused me to realize in a profound way how my isolation wasn't merely affecting me but also all the people in my life.
Curiously, negative emotions and accompanying judgments like guilt and shame didn't emerge, rather a realization that my presence in the lives of others had been very much missed and with that knowledge came a warm feeling of being valued. I was staring at this abstract representation of my relationships when I remembered that I've always depended on them to nourish me in ways I can't account for. And finally, that there is an interconnected nature to all human relationships - with all their complexities – that are not simply conveniences but necessities. For all of us.(1)
My severe depression distorted the way I viewed most everything. I regarded relationships as a series of confusing, demanding and exhausting obligations from which I could no longer account for what I gained. But in that moment, I remembered they're necessities for me whether or not I can articulate the gains derived from them. Remembering this interdependence was both profound and simple and I was awestruck, with one thought that repeated in my mind: “I had no idea, I really had no idea.”(2)
The image dissolved as the music changed and I had a pang of regret. Wait, don't go. I silently told myself to remember this, I must never forget this again.
[If you listen to Maxence Cyrin's piano version of "Where Is My Mind", notice that the piano's pedal noise is picked up and amplified. It didn't occur to me this could have an effect on the context].
My analytic mind dissolved into the song and the image of a grand piano in an empty room appeared in my head. The keys were being played without anyone sitting in front of them, no hands touched them. All sense of my physical form gradually dissolved until my body was actually inside the piano, below the lid, watching the felted hammers strike the metal strings directly above me. This mental construct lasted only for a brief time before the last remnants of my physical body were gone and I and the grand piano became as one. I remember feeling the bass notes in my chest, the treble in my extremities and the pedals were my lungs.
The song was coming from me and being played in me. The entirety of this depersonalization experience lasted perhaps two minutes. Lacking possession of my executive brain functions, I remember feeling rather than thinking how it was okay to become one of the instruments in a song.
Throughout the infusion the blood pressure cuff constricted to measure my vitals and I understood what it was and why it was doing that. The sensation brought my mind back into my body. It also brought anxiety back into mind. As the pressure of the cuff intensified, an anxious thought bubbled up and whispered how this thing on my arm might keep constricting until it popped me like a crushed grape! But then the cuff would finish inflating and I could feel and hear my pulse, steady and vital. If ever I became anxious, this sensation was a reminder of where I was and regardless of where my mind went, professionals were caring for my body. This felt reassuring so I resolved that I would use the cuff constriction as a touchstone if I ever felt the dissociative effects got too intense. Feelings in my body like hunger also helped ground me.
I noticed the uplifting feeling of joy hadn't completely disappeared, lingering for about 3 hours afterwards. I spoke with both the nurse and doctor about my mood change and while I felt lucid, my mind was oddly muted. The usual onslaught of thoughts, attached emotions and the “stories of the mind” that accompanied them - weren't there. Or perhaps they were there, they just didn't seem to matter so much. This “quieting of the mind” lasted for about 6 hours after infusion.
When I arrived home I did my laundry, cooked dinner and washed all the dishes. I noticed how I had more energy to do all this. Perhaps the earlier suggestion that Ketamine treatment improves functionality explains how I felt able to do more, or perhaps it actually was an effect of the treatment. Either way, it didn't matter.
I ended my evening with 10 minutes of guided mindfulness meditation, hoping to cultivate some of these positive effects. I think the meditation helped. At bedtime, I wasn't churning through all that happened that day which is unusual for me. I was able to get to sleep just after 2am, not bad for an insomniac.
The next entry will describe my third infusion, which took place the day after. More dissociation and a moment of realization of the value of human relationships that becomes a sort of therapeutic anchor.
I had a general idea of what might characterize a good playlist and I solicited opinions from several sources to help me form a criteria:
Should be music I like – OK that's pretty obvious
Shouldn't be songs I'm already emotionally attached to – I'm not trying to relive good or bad times
Songs must have no lyrics in a language I know – I want to avoid fixating on subject matter
Favor shorter tracks over longer ones – at least until I know what works and I can always replay a track
Minimalist with repetitive refrains – lesson learned from orchestral music and audio distortion. Repetitive because it is meant to enhance not distract
Drop in a song that cues a relaxation response – a message from sober-me to Ketamine-intoxicated me that says, “Hey whatever is going on right now, know that you're going to be OK - oh and by the way, here's a funny little inside joke.”
My playlist included a lot of ambient music drawn from TV, movie and video game soundtracks that I liked but hadn't yet worn out from excessive playback. Most of the music seemed uplifting to me. For the inside-joke song, I chose “Where Is My Mind” by the Pixies, a piano-only version with no lyrics. One of my favorite songs from one of my favorite bands, I figured I ought to recognize it no matter where my mind had flown to.
Music Changes The Context
The auditory distortions lent an amusing and playful quality to the music and I began to feel joyful, even ecstatic at times. I was aware that I was experiencing the euphoric quality connected with Ketamine and able to lose myself in it while also reflecting upon how long it'd been since I'd felt this good.
When the music changed, the experience changed with it and I felt a small tug of regret that I hadn't included even more happy songs which might prolong this euphoric feeling. I was going to fumble with my iPod buttons to replay the previous selection (no easy task due to the numbness and visual distortion) but then it came to mind that although it was a really pleasant experience, a journey is defined by more than a single experience. The thought gave me tacit permission to let it go. The soft notes of “Where Is My Mind" drifted into my ears and a small smile spread upon my lips.
Next up - dissociative experience and treatment after-effects
I Wanna Feel Everything
You know the feeling of not having had enough sleep. Reduced cognition, lack of alertness and awareness, all the soft-headed sensations. I suffer from chronic insomnia so that's my baseline most days but on this day adrenaline from the 2 mile walk and anticipation of getting the needle compensated. I met with the doctor and nurse and they explained the procedure and answered my many questions. They took vitals, then put me in a soft leather reclining chair and placed a blood pressure cuff on my arm and an O2 saturation/pulse monitor on a finger before undertaking the tortuous task of sticking me. Thankfully, the nurse was very competent and managed to get the catheter into a cooperative vein after only two tries. I have needle phobia so this process sucked more and took a lot longer than it should've.
I didn't bring a companion with me so they asked if I'd like someone to stay by my side and I replied that it didn't really matter to me; do what you do. The nurse informed me that most patients cover their eyes with a sleep mask and their ears with noise-canceling headphones playing music during infusion, it makes for a more inward experience and it's generally more relaxing. Nope, I said. I wanted to be aware of my surroundings so that I could collect all the information I could about the experience. To my thinking, if Ketamine was an effective treatment for depression then it shouldn't matter and since this was my first of six infusions, why not make it a sort of controlled experiment.
I'd come to regret that.
What followed was alot of self-monitoring which certainly didn't make the experience enjoyable. Without distractions, my ever-chatty anxiety was with me in each moment, narrating every perceived drug effect – light nausea, anesthetic numbness and the heavy tongue feeling that gives you. If you've been given Novocaine for a dental procedure you know what I mean. Ketamine is an analgesic so that part is actually nice, any soreness or pain in my body was totally masked. However, this was very different from my recreational drug experiences, I wasn't prepared for the strength of the anesthetic sensation and this and my constant body-monitoring was making me uncomfortable. Five or ten minutes into the infusion, I wondered with some apprehension how strong these effects were going to get. My eyes kept drifting to the IV stuck in my hand.
I began to smell and taste rubber although none was in or around my face, kinda strange(1). I got the doctor's attention and asked him some random question about Transmagnetic Stimulation, or TMS. I wasn't really interested in it, just wanted to try speaking and I think I was also a little scared. I desired an intellectual moment for some semblance of normalcy, The doctor kindly declined my invitation to discuss it and gently suggested that I relax into the experience.
The blood pressure cuff attached arm to my arm constricted every 5 minutes. I used it as a reminder to shift my attention to my breathing so that I wouldn't allow anxiety control the entirety of my awareness.
About 15 minutes into the infusion, things started to get kinda weird.
I'd brought some music with me, Brandenburg Concerto by JS Bach so I decided to listen. This is orchestral music so, lots of instruments playing harmoniously in a precisely composed piece but under the influence of Ketamine, it sounded as if the orchestra was playing in an underground parking structure. Ketamine distorts sounds by giving them a flanging(2) and/or a stuttering effect – which you might be familiar with if you've ever taken Nitrous Oxide. That didn't work well with classical music and after a few tracks I pulled out the earbuds.
I heard the fussing of a young child that seemed to be coming from the hallway outside the door to the treatment room but I wasn't sure if it was real or hallucinatory (turns out it was real). The sound was distorted, stretching into a wail, then stuttering. The noise wasn't bothersome, it was like an anchor to reality and it also called to mind pleasant memories of playfulness as a child.
At about the midpoint of the infusion, things started to get really weird.
Time Perception Distortion/Dilation
I observed the doctor and nurse standing at the foot of my chair looking over some papers attached to a clipboard. I perceived their perfectly still bodies in a kind of frozen, timeless moment that I'll try to describe: they're standing there (at this present moment), they were there - but it was some time ago (like an afterimage) and they will be standing there (the moment is yet to happen). My brain is perceiving and processing all three temporal states as happening in the moment they're observed.
Now, that is some kinda freaky so I'm going to attempt an awkward and inadequate analogy.
Imagine you're observing a pendulum in motion with a strobe light behind it flashing at quick intervals. As you watch it swing, you can't determine at any given moment if it's at it's equilibrium point in the center or in one of many points along it's trajectory. Vision reports to your brain from moment to moment that the pendulum is simultaneously at rest and oscillating.
This perceptual distortion brought with it no feeling of dissonance or anxiety for me, I'm familiar with this effect from my recreational experiences with psychedelic drugs. I regard the event as an “a-ha” moment: were we not creatures forever trapped in linear time, I imagine this is how we might perceive our world.
Some time later though impossible to know how long, I noticed the doctor sitting on a stool by my chair. I probed my feelings, did I feel scrutinized or uncomfortably exposed/vulnerable? No. I self-soothed anyways by acknowledging that it's comforting to know I was being cared for and should anything at all go wrong, there is no safer place I could be than here. I don't see him leave but the doctor vanishes. I probed my feelings again – did I feel lonely? No.
When looking directly at the faces of the doctor and nurse, they appeared elongated or misshapen. This is not the same as a visual hallucination because the external stimulus is actually there. The effect is similar to passing a lens over a photograph, but in three dimensions. I decided it's unpleasant so I looked away.
Completed Infusion And After-effects
For the remainder of the infusion I felt fairly calm despite near-constant monitoring of my body and the drug's effects. I didn't experience any emotional distress, no symptoms of my MDD manifested. My anxiety, whenever it felt present, as felt far away which is strange for me. Anxiety returned at the end if the infusion when the IV machine began to beep and a red light atop the unit began flashing. While the still semi-aware observer in me understood this indicated that the infusion was complete my anxiety, always up to the task of distorting my thoughts, informed me that a red flashing light never, EVER indicates anything good. I was mindful of how silly that sounded and regarded it with mild amusement.
I'd read about Ketamine being a dissociative anesthetic with out of body experiences, commonly referred to in the literature as depersonalization, being a side-effect. One study even suggests the dissociative features of Ketamine might predict a greater antidepressant response(3). Well, there was no dissociative episode in my first infusion which wasn't a let-down, I think. I didn't want the first one to be too overwhelming and I went into it with a view towards collecting information rather than seeking a specific experience.
The nurse informed me she was hanging a saline bag and that I had completed my first transfusion. I felt a sense of pleasure and relief knowing that I had completed the therapy without serious incident. When she spoke she used a lot of hand gestures, which really seemed helpful in that it facilitated communication, I was still very intoxicated. It also conveyed a sort of gentleness and openness - as if careful word choice and sweet intonation could not be trusted to do so alone. Her hand movements left vague trails which I recognized as mild hallucinations. The executive function of my brain seemed to be “waking up” and I was surprised by just how quickly the drug effects seemed to leave my system once the saline flush began.
15 minutes later, the doctor met with me to ask about how I felt and if I felt any change in my mood. I was slightly disappointed to report that I didn't feel an elevation in mood or could report some definitive, significant change in my condition. He explained that only a small number of patients do after their first infusion and referred me to the Ketamine Advocacy Network web page to read more about the therapy and what to expect in the infusions to come.
A family member picked me up and drove me to her house for lunch. I was super hungry and devoured the meal. In the middle of a casual conversation with her, I realized that I felt more “like me” than I had in a year - it's hard to explain the feeling. Afterwards, I felt I had enough energy to walk the 2 miles home. As soon as I arrived I got to work on a musical playlist for my next infusion and realized I was feeling excitement at actively working on shaping the Ketamine therapy. I paused just long enough to acknowledge that I hadn't been excited about about a damn thing in over a year.
I was able to fall asleep with some ease around 1am.
The next post will be about my second infusion which happened the following afternoon and did include a dissociative event. I'll write about how I believe I changed the context of the Ketamine trip using music as a guide and to cue a particular response.
(1) I asked an Anesthesiologist if he could explain the rubbery taste and smell. He said strange tastes and odors can be rare after-effects of general anesthesia but he'd never heard of this in connection with Ketamine. I'd been put under with inhalation anesthetic for surgery before and it occurred to me that my first experience was when I was only 6 or 7 years old. Back then, anesthesia gas was delivered through rubber tubes. Did Ketamine's anesthetic sensations in my body trigger a sort of recollection of that taste?
(2) See Flanging in Wikipedia to listen to a sample of this sound effect.
(3) "Ketamine-Induced Dissociative Symptoms Predict Antidepressant Response", Psychiatry Advisor, May 17, 2018.
Make Me A Believer
I really hate indoctrination. But hey, any port in a storm, right? There are lots of reasons to be skeptical about Ketamine treatment but nevertheless, I decided to set aside my doubts and buy into the notion that it could help me rewire my brain. This began with accepting that depression had a physical impact on my brain, developing neural networks strengthened by frequent use which were rather unhealthy and I wanted to alter them. But how? I read up on neural plasticity and dendrite excitement, synaptic regeneration, even watched a boring video of a scan of a rat’s brain on Ketamine.
In doing this I was able to convince myself that the therapeutic value of the drug is not limited by how long it remains in the body. Rather, the lasting effects must have something to do with how patient and therapist can leverage the impact on neural networks in some manner that results in psychological transformation.
Just writing that makes me think of out-there “woo-woo” stuff and I admit, it sounds like a big reach. I probably misused some words because I lack the vocabulary to describe it in scientific terms so, just bear with me.
At bedtime, I was very anxious. I knocked back 100mg of Trazodone and crawled into bed hoping to get some rest. Moments later, the dynamic duo of Anxiety and Depression, like a pair of unwelcome pals at the local bar, pulled over a couple of chairs to count off the reasons I should dread tomorrow.
If you want a cheap laugh at my inner dialog with my two pals Anxiety and Depression, enjoy.
I got about 2 hours of sleep.
The list things you aren't allowed to do before infusion is long and crappy. You must fast for at least 10 hours. No liquids except water or plain tea. No Benzodiazepines, no Gabapentin. No alcohol. No drugs at all except for your antidepressant and necessities like allergy meds and stuff they think is OK.
I decided I would walk 2 miles to the clinic because I read that exercise does good stuff for the brain, blah, blah, blah would you just get on with the infusion story, pal? Ok...
Male, 48 years old at the time of this writing diagnosed with Major Depressive Disorder (MDD) treatment refractory and Generalized Anxiety Disorder (GAD). Mental Illness runs in both sides of my family, my mother was diagnosed but her mom wasn't and while she died before I was born, by all accounts she was 32 flavors of effed up. For treatment, I've gone through the most popular categories in the antidepressant alphabet soup– SSRIs, NDRI, SNRI, Tetracyclic and Trycyclic experiencing zero relief even at maximum therapeutic doses and in various combinations. I experience periodic panic attacks for which I was prescribed Benzodiazepines. I have chronic insomnia and was given medications in the hypnotic class – which did not help - so until recently I self-medicating with Cannabis.
In addition to mental illness I have an autoimmune-related skin condition called Lichen Planus for which there is no understood cause or cure. It's characterized by an itchy rash that appears and spreads and then completely goes away whenever it wants. I'm also diagnosed with a rare inner ear disorder in my left ear known as Ménière's disease for which there is no cure or treatment and is characterized by hearing loss and sudden, random episodes of debilitating vertigo lasting 20 minutes to 8 hours.
Major Depression Strikes
I experienced bouts of depression throughout childhood and adolescence and two major depressive episodes in my adult life. The first major episode came in 2006 and followed a job loss and the end of 12 year relationship. For 4 years I felt like a ghost, isolating myself from family and friends unable to job hunt, unable to socialize apart from the online gaming community I'd thrown myself into.
One random day, I woke up angry at myself and my hopelessness and decided I needed help. Rather than seek it from a mental health professional, I bought some books on meditation and began practicing. I also started walking 2-5 miles everyday. Together, this seemed to work, I began to feel empowered and my symptoms went into partial remission. By then, I'd been out of the job market about 6 years so I chose volunteer work in my field of expertise which I did for a year before seeking and landing a new job. I started dating again and showed up to absolutely anything anyone invited me to, no matter how weird or uninteresting. I still experienced anxiety and insomnia but I managed. At that time I well feeling self-assured and so very proud of having beat depression, touting my “Meditation, not medication!” slogan to just about everyone I knew.
Yeah. Pride no longer follows the statement.
Major Depression Strikes back
My second major depressive episode happened in 2014. I don't even recollect if how exactly began, depression is such an insidious disease. I know my mental health deteriorated when I was fired from my job and undertook end-of-life care for my father, who was slowly dying of heart failure. At the urging of my partner who was taking antidepressants, I finally sought help from a psychiatrist. I was prescribed antidepressants, went to biweekly therapy and joined therapy group classes to address the depression and anxiety. I didn't respond to the drugs but the classes were kind of helpful. I had trouble digesting the information, difficulty concentrating and remembering what we covered. My psychiatrist followed a drug protocol, increasing dosage to therapeutic maximum or limits of my tolerance, then augmenting with another medication followed by tapering off before introducing a new class of antidepressants.
Despite the treatments and therapy, my mental health continued to slide. I became frequently irritable, frustrated and hopeless. I had emotional meltdowns and lashed out at family, friends and my partner. For more than a year, I sunk into severe depression with loss of even basic functionality. I couldn't leave my house and felt unable to respond to invitations, phone calls or texts. I went to couples counseling in addition to the other therapy work but it wasn't helping. I didn't feel that anything in my life had value, so I left the relationship. After that, I felt emotionally numb, experienced anhedonia which was followed by suicidal ideation.
You Want To Shoot Me Up With What?
I first learned of Ketamine treatment for depression from my therapist. Let me tell you that I consider myself a skeptic, which in terms of healthcare means, I need there to be peer-reviewed, science-based evidence if I'm to believe a treatment has any merit. There's so much utter nonsense out there – especially in California, where I live. I read whatever I could find about Ketamine but was underwhelmed by the body of evidence supporting it's efficacy in treating depression, unimpressed by testimonials (the plural of “anecdote” is not “evidence”)* and dismissive of articles in popular magazines which I deemed sensationalized.
I was honestly confused as to why any doctor would prescribe Ketamine treatment when it seemed they understood so little about the mechanism by which it treats depression.
And yet, Ketamine treatment is covered by my insurance and they actually have their own program going for treating their patients. Nevertheless, it still took me 6 months of agonizing, soul-crushing MDD symptoms from when I was initially recommended for the program until I finally agreed to participate.
The blog entries that follow are my experiences in the Ketamine treatment program starting with the first of 6 intravenous infusions, which began in June 2017.