The Use of Ketamine in Psychiatry

E. KHORRAMZADEH, M.D., AND A. O. LoTPY, M.D.

INTRODUCTION (E.K.) present during the drug administration.

Ketamine hydrochloride has been used as a The abreactive effect was considered present
short acting anesthetic agent.u,s The present when patients demonstrated 1) excitement, 2)
report is, to the best of our knowledge, the first emotional discharge, 3) verbalization of con-
investigation into the use of this chemical as flict, and 4) emergence phenomenon. When-
an abreactive agent. Additional investigations ever there was no spontaneous response, the
have related to the Ketamine's mind expanding abreactive effect was induced by verbal stimu-
effects. lation. Mind expanding effects of the drug were
determined through patient interviews. Pa-
MATERIALS AND METHODS tients were then evaluated in terms of facilita-
Subjects were chosen from the inpatient pop- tion of psychotherapy and symptom relief. The
ulation of a psychiatric unit of a university period of observation extended from immedi-
hospital in southern Iran. Description of the ate to up to a year.
area and hospitals are presented elsewhere.·
RESULTS
Patients with organic brain syndrome and psy-
choses were excluded. A total of 100 patients The sex distribution of the 100 subjects as
were investigated. Each patient was told an well as their psychiatric diagnosis is presented
overview of the technique and a written per- in Table I. The youngest was 16 and the oldest
mission for the treatment was obtained. 66.
Patients who entered the study were kept The first group received 0.2-0.3 mg of Keta-
NPO for 4 hours. They were then put to bed mine/kg body weight. Of the 25 subjects in
on a supine position and received 0.5 mg of this group, only 1 had the minimal anesthetic
atropine in~avenously. Subsequently, Keta- response, i.e. speech disorder. This was the
mine was administered, also intravenously. To only patient who also responded with abre-
determine the optimal Ketamine dose, the drug action and the psychotherapy was facilitated.
was administered in 3 dose ranges. In fact, the patient left the hospital 1 week
The first group (25 patients) received 0.2 later. The diagnosis was dissociative reaction
to 0.3mg/kg body weight. The second group and she has been observed for a year with com-
(96) which included 24 from the first group, plete relief of symptoms. In all, 24 out of the
received 0.4 to 0.6 mg/kg body weight of the 25 in this first group showed neither the mini-
drug. The third group of 4 patients were given
0.7 to 1.0 mg/kg body weight of Ketamine. TABLE I

To determine the anesthetic effect of the Number of Patients

drug, subjects were asked to count backward Diagnoses Male Female
Anxiety reaction 8 2
and errors in counting or speech d:sorders
Di>sociative reaction 5 I
were considered significant. Phobic reaction 6 I
The abreactive effect of the drug was evalu- Obsessive compulsive reaction 3 0
ated by observation on part of a psychiatrist Conversion reaction 2 9
Hyster ical convulsions o 13
Hypochondriasis 19 4
Dr. Kho;nmzadeh is Assistant Professor, Dept. of Depressive reaction 3 4
Psychiatry, Pahlavi University School of Medicine, Tension headache 10 5
Shiraz, Iran. Ulcerative colitis S 0
Dr. Lotfy is Professor, Dept. of Anesthesiology,
Pahlavi University School of Medicine, Shi;az, Iran. Total 61 39
344 Volume XIV
 USE OF KETAMINE-KHOIlRAMZADEH

mal anesthetic effect nor the abreaction re- his hands and his inability to catch them.
sponse. These 24 were then given a higher dose All patients who responded also exhibited
of Ketamine (0.4-0.6 mg/kg body weight) disorientation in all 3 spheres. Seventy-four
along with 72 others, a total of 96 had the subjects also had hallucinatory experiences in
minimal anesthetic response while 95 demon- the form of a 2 way discussion, together with
strated the abreactive response. Of the latter, excitement which reached a peak and was fol-
all had facilitation of their psychotherapy and lowed by a sudden silence lasting thirty sec-
symptom relief. The one who did not respond onds. This rise and fall of excitement occurred
had severe tension headaches. a minimum of 3 and a maximum of 14 times.
Group 3 included only 1 failure from the As the effect of the drug was wearing off,
group 2 as well as 3 new patients. They re- silences became briefer and there was an ade-
ceived 0.7-1.0 mg Ketamine/mg of body quate verbal response.
weight. All of these patients showed the an- Fifty-one patients recalled vividly painful
esthetic as well as the abreactive response and childhood events regarding the key figures in
they all had facilitation of their psychotherapy that period. In 4 cases the abreactive and/or
and symptom relief. the mind exploration lasted more than 2 hours.
It should be noted that all patients had "a And, while 6 patients had 45 minutes of abre-
loss of contact" ranging from 25 seconds to action or mind exploration, in the remaining
up to 4 minutes in which they had the typical patients this period was about 75 minutes.
schizo-anesthetic appearance (a peculiar look Acceptability
described as an absent minded individual de-
Patients reaction: The first patient, with
tached from the present and fixed on infinity). 3
anxiety reaction, did well during the procedure
To sum, all patients responded in every and only complained of mild dizzy spells which
parameter if a sufficiently high enough dose of lasted 2 hours. The second patient was a male
Ketamine was administered. with a long-standing conversion reaction which
The mind expanding effects of Ketamine cor- was resistant to conventional psychotherapy.
related with abreactive response. Interviews He manifested severe excitement, loud scream-
and observations revealed patient reactions ing and foul language all of which were con-
such as: "I always wished to scream", "I al- trary to his well controlled and composed be-
ways desired to make nasty remarks but dared havior on the ward. This produced a commo-
not", "The injection took away the discomfort tion among the other patients who were eaves-
in my chest", "Heavy burden of sin is gone dropping in an adjacent corridor, but the fol-
now", "I now feel carefree with no worries", lowing day when this patient (after a night of
and "As a child I always wanted to shout but sound sleep) told his room-mates of how re-
they did not let me." Other statements cate- laxed and great he felt after the injection, many
gorized as psychic changes included: "I was patients volunteered for the same injection.
in a different world and with flash backs I was Complications noted after Ketamine treat-
seeing vividly events which led to my illness", ment included 2 patients with vomiting and 3
"Colors disappeared and I saw only in black with nausea. In 2 patients with severe deper-
and white", "I was talking to the Holy Family", sonalization which had caused severe appro-
"I was walking everywhere and seeing every- hension, the experiment was ended with Per-
thing", "I was walking on an infinite piece of phenazine (5 mg. i.m.). Perphenazine was
land and my life was marching in front of my also used in those with nausea and vomiting
eyes", "The blue sky was squeezing my chest", with a favorable response.
"I was flying and chasing my own life", and "I Once the ordeal was over, the patients were
was facing the forgotten memories and was asked "What had happened" and "How they
ashamed of them." Two patients felt that their felt" in order to make the experience accessible
extremities were no longer attached to their to their consciousness for a later interview or
trunk. One other experienced the floating of interpretation. They vividly recalled all events,
November-December, 1973 345
 PSYCHOSOMATICS

at times with encouragement. Finally, 78 pa- thetic response was required for the expected
tients felt so tired that they wished to be left abreactive effect. In all, Ketamine at 0.4-0.6
alone in order so that they could sleep. mgjkg body weight led to minimal anesthetic
All of the subjects were seen 6 months after effect and the abreactive response in nearly all
the injection. Only 9 patients were not doing of the subjects. The abreactive effect correlated
well at this time. Two of these had latent well with the Ketamine's mind expanding ef-
homo-sexuality and obsessive compulsive neu- fects.
roses. The others had hypochondriasis with Ketamine was found to be a fast acting drug
paucity of intellectual functioning and a poor with a short duration of action. It induced
adjustment to their work and family life. regression, introversion, lability of mood and
Ninety-one of the patients were doing quite perceptful disturbances. Moreover, it led to a
well. loss of time sense and detachment from the en-
After one year, 88 patients were still being vironment. It activated the unconscious and
observed and all except two were doing well repressed memories, while it temporarily trans-
(one had ulcerative colitis, the other tension ported the patient back into childhoOd with
headaches). Interestingly they both requested frightening reality, reviving traumatic events
another injection which was given and led to with intense emotional reaction. Some had
relief of symptoms for the brief period of fol- recall of events leading to their illness. Inter-
low up just prior to completion of this manu- estingly, patients showed a good degree of
script. verbosity and inhibitions were gone.
DISCUSSION
Within one year of follow up, nearly all pa-
tients had" remained well, though 2 required a
In 1959 Phencylidine was found to be a use-
second injection. The complications were very
ful anesthetic agent.1i Simultaneously, its
minimal and included apprehension (2 sub-
schizophrenomimetic properties were also ob-
jects), nausea (3 subjects), and vomiting (2
served. 6 Because of its many side effects, Phen-
subjects). In conclusion, Ketamine was found
cylidine was abandoned though attempts at dis-
to be a safe psychotomimetic agent.
covery of its less hazardous derivatives con-
tinued. 1i Pahlavi University, School of Medicine, Sbiraz, Iran.
One such compound was found to be 2-(0 REFERENCES
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thetic agent, Ketamine was found to induce a ciative anesthetic in man. CUn. Pharmacal. Ther.
profound analgesia combined with an uncon- 6:279, 1965.
2. Corssen, G. and Domino, E.F.: Dissociative anes·
sciousness in which the patient appears discon-
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logically, Ketamine is categorized as a dissoci- ative CI·581. Anesth. and Ana/g. 45:29, 1966.
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