A 48-year-old Japanese man with severe chronic primary low back pain reported over 360 dreams during insight-oriented psychotherapy from 2009 to 2025. In 2014, he received five low-dose intravenous ketamine infusions (15 mg; 0.23 mg/kg) and described a void-like dissociative state during the first session. After coding a random subset of 50 dreams, obstruction decreased from pre- to post-ketamine periods (treating clinician: 6/9 vs 4/30; external psychiatrist: 6/9 vs 7/30), while a social-interaction/role-completion motif increased post-ketamine (2/9 pre; 10/30 and 11/30 post). Dream content shifted from recurrent obstruction toward imagery of movement, interpersonal engagement, and everyday role completion. These hypothesis-generating observations describe ketamine-associated phenomenology and longitudinal dream-content change without making efficacy claims.
Ketamine's effects vary across patients and sessions, so dose alone does not explain them. A Gate-Amplifier-Reintegration framework proposes that awake low-dose ketamine amplifies transient network flexibility, while autonomic-salience stability acts as a Gate that may steer this flexibility toward reintegration or dysphoric dissociation. The three-step sequence involves Gate (candidate autonomic-salience stability), Amplifier (ketamine under conditions preserving vigilance), and Reintegration (organizing flexibility into language, attention, and action). Heart-rate variability serves as a peripheral state-verification proxy. The framework is informed by nonrandomized clinical observations from a single-center outpatient chronic pain care pathway, which provide clinical provenance but not comparative efficacy evidence. Falsifiable predictions include prospective Gate manipulation altering pre-dose autonomic state and randomized designs testing mediation of tolerability and clinical change.