Mental Health and Ketamine: Part I

~ This blog series is about my approach to mental health and the integration of ketamine therapy with a psychodynamic and affective neuroscientific lens ~



Any approach to mental health should start with an understanding of what constitutes a “normal” psychological state. As simple as it may seem, it is quite the opposite: determining what is ‘normal’ is largely based on the familial culture (independence, interdependence, belief systems), social culture (broader values), and the interaction between people who make up those groups and the individual. For example, in the U.S, fundamentally built on a Judeo-Christian framework, many of our ‘normals’ are codified in both social and written law with that framework built in, and when someone transgresses the code there are known consequences regardless of religious affiliation. Such constraints make it necessarily simple to know where an individual is on a scale of normality – and people are pretty quick to broadcast when you are too close or beyond the acceptable range. It is simply the game we are all playing, knowingly or not, and it has been relatively successful given the economic prosperity of the country. However, economic success is not the only measure of whether or not a cultural system and its effect on people translates into what should be construed as the norm. Some would argue that the game is rigged to disenfranchise those who cannot contribute in an economically meaningful way. Well, this blog is not an attempt to criticize or support the country’s mode of being, but to point out that much of our behavior is programmed from an early age based on societal, including immediate family, values, and that such subconscious layering may be at odds with the later development of critical thought and the switch from inherited morality to a mode of ethics with a more personal flavor. So now I ask – what is normal?

From my perspective, to be normal means that a person is able to react to events and phenomena with a degree of emotional arousal that will still allow for critical thought, introspective processing, and deliberate responses. With those parameters, I’ll say that hardly anyone is normal, and that includes myself at times. Does intermittent abnormalcy indicate psychopathology? It depends on how far off the normal train one falls, and for how long. Emotional arousal is an indicator that something is important and worth paying attention to. It is fundamentally anticipating or conveying the presence of something potentially rewarding or harmful. Importantly, the level of arousal is typically not up to the individual, but at the mercy of their early childhood development when the evolutionarily inherited emotional motivational systems guide survival. Here, we will take a segue into the theoretical framework through which I approach neuropsychology.

The Affective Roots

The work of Jaak Panksepp and colleagues have put forth a theory of emotion called affective neuroscience, which looks at the development of consciousness through the lens of primary-process emotional (affective) motivations. These primary process systems all reside in sub-cortical midline structures of the brain, our evolutionarily oldest structures that are shared among all mammals, less so in birds, and lesser still in reptiles. Even crayfish demonstrate affectively motivated behaviors, which reveals how truly old some of these structures are. That being said, there are currently seven identified neurological circuits that are responsible for generating primary-process emotions: SEEKING, LUST, FEAR, RAGE, CARE, GRIEF, and PLAY (capital letters are used to emphasize the circuits as distinct entities, not to be associated only with their semantic meaning). Electrical stimulation of core nodes in these circuits repeatedly demonstrate distinct affective behaviors that are unconditioned, which means they are not learned, but genetically endowed. These systems provide a scaffolding for consciousness to emerge. If we did not have positive or negative affective motivations to compel action and to assign value to pursuits, then consciousness would have little purpose. I will briefly review each system.

  1. SEEKING – The primary source of positive emotion is found in this system. The nodes of the SEEKING system are responsible for generating desire to explore and exploit potential, whether it is a new location to forage or the euphoria of escaping a dangerous situation. All purposeful pursuits are fueled by the dopamine driven SEEKING circuitry. It is wrong to view this system as the ‘reward’ circuit in the traditional sense because it does not govern the reward following the consummation of a pleasurable thing. Instead, it governs the pleasure of pursuing a goal/purpose/object/behavior – it is the generator of incentive reward. As steps are taken that indicate steady progress toward a desired end, dopamine is released in proportion to the progress in order to promote its continued pursuit. Stimulatory drugs of abuse, like cocaine, amphetamines, and nicotine are addictive because the hijack the SEEKING system and falsely indicate that a hard-earned reward is close to attainment.

  2. FEAR – The source of unconditioned responses to loud noises, offensive/predatory smells, sudden movements, open spaces and uncertainty, and pain. Responses include increased heart rate, blood pressure, freezing, and with enough SEEKING or RAGE input, fleeing or fighting, respectively.

  3. RAGE – The source of instinctual and defensive aggression. The unconditioned feelings of RAGE are brought about by rejection, withdrawal of expected reward, physical restraint, and prolonged homeostatic (hunger, thirst, sex) imbalance. It is important to note that ancestral RAGE is not anger, which typically is aimed at an object/person/process, but a raw feeling that I feel is best conceptualized as the ‘fight’ part in the ‘fight or flight’ sympathetic nervous system response to threat. The evolution of RAGE in to higher-order cognitive processes like anger, frustration, revenge, wrath, annoyance, and resentment is mediated by environmental and social factors rather than neurobiological inheritance.

  4. LUST – The ancestral source of reproductive energy. Coupled with SEEKING, LUST circuitry motivates the pursuit of procreative behavior after sex hormones have begun to circulate. LUST circuitry is sexually dimorphic, meaning the parts of the brain that give rise to the affect are different in men and women.

  5. GRIEF – Also labeled as the SEPARATION DISTRESS circuit, this system is at the root of negative affect and emotion in humans. Thought to have emerged alongside the CARE circuit, GRIEF, in its most simple purpose, activates distress behaviors (such as crying) that occur when an infant’s mother is not present to help the child satisfy their need for nurturing. As the brain develops and more cognitive tools are available to the individual, more intricate emotional states and cognitive justifications are able to compound on top of GRIEF to form complexes that reflect resilience or fragility, depending on how well GREIF was managed.

  6. CARE – A classically feminine circuit, the CARE system engenders maternal behavior at the onset of pregnancy, and throughout the child-rearing process. That being said, elements of CARE are seen early on in well-adjusted kids where, in combination with PLAY, they are able to begin developing a theory of mind, where they consider what others may be thinking or feeling across various circumstances. Parenting and sociocultural pressures that promote an always-be-nice mentality, characterized by non-confrontational, non-judgmental, non-aggressiveness, etc. may sensitize the CARE circuit outside of the context of child-rearing and lead to excessive empathy and desire to take others’ problems on their conscience. Such an emphasis comes with the potential cost of not integrating RAGE, PLAY, and other systems.

  7. PLAY – Proposed to be the newest of the evolved affective circuits, as it is only observed in mammals, the PLAY circuit is a potent generator of positive emotion and joy. PLAY seems to be necessary for the appropriate development of the large frontal lobes that aid in executive decision making, planning, and reflection. Without an outlet for PLAY, hyperactivity and inattention are seemingly inevitable consequences.

In the early years of life our experiences are dominated by these systems. As foundational systems of emotional development, it is no wonder that things like trauma, neglect, over-protection, and other childhood misfortunes can promote abnormal emotional arousal in response to events or circumstances that prevents critical thought, introspective processing, and deliberate responses. Affect is at the root of any learning process, motivation, and valuation. This is why, in emotional dysregulation and mental health disorders, affect is king. With this understanding and theoretical basis for the development of both resilient and fragile mental health, we can appreciate how peeling back layers of affective life and uncovering unconscious patterns of emotional behavior can contribute to more resilient mental health. However, the psychotherapeutic path into affective life is neither simple nor easy, as years and years of secondary and tertiary-level defenses, beliefs, and values have been built like sky-scrapers atop the affective foundations. This is where ketamine and psychodynamic therapy play a crucial role. These topics will be covered in the follow-up parts II and III.