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Anna Lembke: Dopamine Nation, Finding Balance in the Age of Indulgence

Dopamine Nation

Scientists rely on dopamine as a kind of universal currency for measuring the addictive potential of any experience. The more dopamine in the brain’s reward pathway, the more addictive the experience.

The secret to finding balance is combining the science of desire with the wisdom of recovery.

The Pursuit of Pleasure

Our Masturbation Machines

The term double life is as familiar to me as ST segment elevation is to the cardiologist, stage IV is to the oncologist, and hemoglobin A1C is to the endocrinologist. It refers to the addicted person’s secret engagement with drugs, alcohol, or other compulsive behaviors  hidden from view, even in some cases from their own.

Addiction broadly defined is the continued and compulsive consumption of a substance or behavior (gambling, gaming, sex) despite its harm to self and/or others.

Supply has created demand as we all fall prey to the vortex of compulsive overuse. Our dopamine economy, or what historian David Courtwright has called “limbic capitalism,” is driving this change, aided by transformational technology that has increased not just access but also drug numbers, variety, and potency.

With increasing access and potency, polypharmacy — that is, using multiple drugs simultaneously or in close proximity — has become the norm.

The world now offers a full complement of digital drugs that didn’t exist before, or if they did exist, they now exist on digital platforms that have exponentially increased their potency and availability. These include online pornography, gambling, and video games, to name a few.

Seventy percent of world global deaths are attributable to modifiable behavioral risk factors like smoking, physical inactivity, and diet. The leading global risks for mortality are high blood pressure (13 percent), tobacco use (9 percent), high blood sugar (6 percent), physical inactivity (6 percent), and obesity (5 percent). In 2013, an estimated 2.1 billion adults were overweight, compared with 857 million in 1980. There are now more people worldwide, except in parts of sub-Saharan Africa and Asia, who are obese than who are underweight.

Our compulsive overconsumption risks not just our demise but also that of our planet. The world’s natural resources are rapidly diminishing.

Running from Pain

Perceiving children as psychologically fragile is a quintessentially modern concept. In ancient times, children were considered miniature adults, fully formed from birth.

Today, many parents I see are terrified of doing or saying something that will leave their child with an emotional scar, thereby setting them up, so the thinking goes, for emotional suffering and even mental illness in later life.

Our efforts to insulate our children from adverse psychological experiences play out not just in the home but also in school.

I worry that we have both oversanitized and over-pathologized childhood, raising our children in the equivalent of a padded cell, with no way to injure themselves but also no means to ready themselves for the world.

Over the past three decades, I have seen growing numbers of patients like David and Kevin who appear to have every advantage in life — supportive families, quality education, financial stability, good health — yet develop debilitating anxiety, depression, and physical pain.

Prior to the 1900s, doctors believed some degree of pain was healthy.

By contrast, doctors today are expected to eliminate all pain lest they fail in their role as compassionate healers.

The paradigm shift around pain has translated into massive prescribing of feel-good pills. Today, more than one in four American adults — and more than one in twenty American children — takes a psychiatric drug on a daily basis.

Beyond extreme examples of running from pain, we’ve lost the ability to tolerate even minor forms of discomfort. We’re constantly seeking to distract ourselves from the present moment, to be entertained.

Along similar lines, Neil Postman, the author of the 1980s classic Amusing Ourselves to Death, wrote, “Americans no longer talk to each other, they entertain each other. They do not exchange ideas, they exchange images. They do not argue with propositions; they argue with good looks, celebrities, and commercials.”

We’re all running from pain. Some of us take pills. Some of us couch surf while binge-watching Netflix. Some of us read romance novels. We’ll do almost anything to distract ourselves from ourselves. Yet all this trying to insulate ourselves from pain seems only to have made our pain worse.

The number of new cases of depression worldwide increased 50 percent between 1990 and 2017.

Thirty-four percent of Americans said they felt pain “often” or “very often,” compared to 19 percent of people living in China, 18 percent of people living in Japan, 13 percent of people living in Switzerland, and 11 percent of people living in South Africa.

The reason we’re all so miserable may be because we’re working so hard to avoid being miserable.

The Pleasure-Pain Balance

Neurotransmitters are like baseballs. The pitcher is the presynaptic neuron. The catcher is the postsynaptic neuron. The space between pitcher and catcher is the synaptic cleft. Just as the ball is thrown between pitcher and catcher, neurotransmitters bridge the distance between neurons: chemical messengers regulating electrical signals in the brain.

Dopamine was first identified as a neurotransmitter in the human brain in 1957 by two scientists working independently: Arvid Carlsson and his team in Lund, Sweden, and Kathleen Montagu, based outside of London.

Dopamine is not the only neurotransmitter involved in reward processing, but most neuroscientists agree it is among the most important.

Dopamine may play a bigger role in the motivation to get a reward than the pleasure of the reward itself. Wanting more than liking.

The more dopamine a drug releases in the brain’s reward pathway (a brain circuit that links the ventral tegmental area, the nucleus accumbens, and the prefrontal cortex), and the faster it releases dopamine, the more addictive the drug.

Release of dopamine in our brain’s reward pathway. For a rat in a box, chocolate increases the basal output of dopamine in the brain by 55 percent, sex by 100 percent, nicotine by 150 percent, and cocaine by 225 percent.

Amphetamine, increases the release of dopamine by 1,000 percent. By this accounting, one hit off a meth pipe is equal to ten orgasms.

Neuroscientists have determined that pleasure and pain are processed in overlapping brain regions and work via an opponent-process mechanism.

In the 1970s, social scientists Richard Solomon and John Corbit called this reciprocal relationship between pleasure and pain the opponent-process theory: “Any prolonged or repeated departures from hedonic or affective neutrality . . . have a cost.”

With repeated exposure to the same or similar pleasure stimulus, the initial deviation to the side of pleasure gets weaker and shorter and the after-response to the side of pain gets stronger and longer, a process scientists call neuroadaptation.

Needing more of a substance to feel pleasure, or experiencing less pleasure at a given dose, is called tolerance.

With prolonged, heavy drug use, the pleasure-pain balance eventually gets weighted to the side of pain.

The paradox is that hedonism, the pursuit of pleasure for its own sake, leads to anhedonia, which is the inability to enjoy pleasure of any kind.

The pleasure-pain balance is triggered not only by reexposure to the drug itself but also by exposure to cues associated with drug use.

In the world of neuroscience, this is called cue-dependent learning, also known as classical (Pavlovian) conditioning.

The motivation to gamble is based largely on the inability to predict the reward occurrence, rather than on financial gain.

The brain encodes long-term memories of reward and their associated cues by changing the shape and size of dopamine-producing neurons.

This process is called experience-dependent plasticity.

With prolonged and repeated exposure to pleasurable stimuli, our capacity to tolerate pain decreases, and our threshold for experiencing pleasure increases.

Without pleasure we wouldn’t eat, drink, or reproduce. Without pain we wouldn’t protect ourselves from injury and death.

Our brains are not evolved for this world of plenty. As Dr. Tom Finucane, who studies diabetes in the setting of chronic sedentary feeding, said, “We are cacti in the rain forest.” And like cacti adapted to an arid climate, we are drowning in dopamine. The net effect is that we now need more reward to feel pleasure, and less injury to feel pain. This recalibration is occurring not just at the level of the individual but also at the level of nations.

Self-Binding

Dopamine Fasting

A framework I’ve developed over the years for talking with patients about the problem of compulsive overconsumption. This framework is easily remembered by the acronym DOPAMINE.

  • The d in DOPAMINE stands for data. I begin by gathering the simple facts of consumption.
  • The o in DOPAMINE stands for objectives for using. Even seemingly irrational behavior is rooted in some personal logic.
  • The p in DOPAMINE stands for problems related to use. Most of us are unable to see the full extent of the consequences of our drug use while we’re still using. High-dopamine substances and behaviors cloud our ability to accurately assess cause and effect.
  • The a in DOPAMINE stands for abstinence. Abstinence is necessary to restore homeostasis, and with it our ability to get pleasure from less potent rewards, as well as see the true cause and effect between our substance use and the way we’re feeling. The question is: How long do people need to abstain in order to experience the brain benefits of stopping? At two weeks, patients are usually still experiencing withdrawal. They are still in a dopamine deficit state. On the other hand, four weeks is often sufficient.
  • The m of DOPAMINE stands for mindfulness. Mindfulness is a term that is tossed around so often now, it has lost some of its meaning. Mindfulness is simply the ability to observe what our brain is doing while it’s doing it, without judgment.
  • The i of DOPAMINE stands for insight. I have seen again and again in clinical care, and in my own life, how the simple exercise of abstaining from our drug of choice for at least four weeks gives clarifying insight into our behaviors. Insight that simply is not possible while we continue to use.
  • The n of DOPAMINE stands for next steps. This is where I ask my patients what they want to do after their month of abstinence.
  • The e and final letter of DOPAMINE stands for experiment. This is where patients go back out into the world armed with a new dopamine set point (a level pleasure-pain balance) and a plan for how to maintain it.

The question of how to moderate is becoming an increasingly important one in modern-day life, because of the sheer ubiquity of high-dopamine goods, making us all more vulnerable to compulsive overconsumption, even when not meeting clinical criteria for addiction.

Space, Time, and Meaning

Self–binding. It is the way we intentionally and willingly create barriers between ourselves and our drug of choice in order to mitigate compulsive overconsumption. Self-binding is not primarily a matter of will, although personal agency plays some part. Rather, self-binding openly recognizes the limitations of will. The key to creating effective self-binding is first to acknowledge the loss of voluntariness we experience when under the spell of a powerful compulsion, and to bind ourselves while we still possess the capacity for voluntary choice.

Self-binding can be organized into three broad categories: physical strategies (space), chronological strategies (time), and categorical strategies (meaning).

It turns out that willpower is not an infinite human resource. It’s more like exercising a muscle, and it can get tired the more we use it.

Another form of self-binding is the use of time limits and finish lines.

High-dopamine goods mess with our ability to delay gratification, a phenomenon called delay discounting. Delay discounting refers to the fact that the value of a reward goes down the longer we have to wait for it.

In today’s dopamine-rich ecosystem, we’ve all become primed for immediate gratification. We want to buy something, and the next day it shows up on our doorstep. We want to know something, and the next second the answer appears on our screen.

The neuroscientist Samuel McClure and his colleagues examined what parts of the brain are involved in choosing immediate versus delayed rewards. They found that when participants chose immediate rewards, emotion- and reward-processing parts of the brain lit up. When participants delayed their reward, the prefrontal cortex — the part of the brain involved in planning and abstract thinking — became active.

Ingestion of high-dopamine goods is not the only variable that influences delay discounting. For example, those who grow up in resource-poor environments and are primed with mortality cues are more likely to value immediate rewards over delayed rewards compared to those who are similarly primed and grow up in resource-rich environments.

Another variable contributing to the problem of compulsive overconsumption is the growing amount of leisure time we have today, and with it the ensuing boredom.

Dopamine consumption is not just a way to fill the hours not spent working. It has also become a reason why people are not participating in the workforce.

The Stanford marshmallow experiment was a series of studies led by psychologist Walter Mischel in the late 1960s at Stanford University to study delayed gratification.

The researchers discovered that of approximately one hundred children, one-third made it long enough to get the second marshmallow. Age was a major determinant: the older the child, the more able to delay. In follow-up studies, children who were able to wait for the second marshmallow tended to have better SAT scores and better educational attainment, and were overall cognitively and socially better-adjusted adolescents.

As Immanuel Kant wrote in The Metaphysics of Morals, “When we realize that we are capable of this inner legislation, the (natural) man feels himself compelled to reverence for the moral man in his own person.” Binding ourselves is a way to be free.

A Broken Balance?

Here are some of the things I worry about in using medications to press on the pleasure side of the balance.

  • First, any drug that presses on the pleasure side has the potential to be addictive.
  • Second, what if these drugs don’t actually work the way they’re supposed to, or worse yet, make psychiatric symptoms worse in the long run?

Recent data show that even antidepressants, previously thought not to be “habit forming,” may lead to tolerance and dependence, and possibly even make depression worse over the long haul, a phenomenon called tardive dysphoria.

What if taking psychotropic drugs is causing us to lose some essential aspect of our humanity

In medicating ourselves to adapt to the world, what kind of world are we settling for?

Psychiatric drugs are prescribed more often and in larger amounts to poor people, especially poor children. According to the 2011 data from the National Health Interview Survey of the CDC’s National Center for Health Statistics, 7.5 percent of American children between the ages of six and seventeen took a prescribed medication for “emotional and behavioral difficulties.”

The Pursuit of Pain

Pressing on the Pain Side

Dopamine rose gradually and steadily over the course of the cold bath and remained elevated for an hour afterward. Norepinephrine rose precipitously in the first thirty minutes, plateaued in the latter thirty minutes, and dropped by about a third in the hour afterward, but it remained elevated well above baseline even into the second hour after the bath.

Other studies examining the brain effects of cold-water immersion in humans and animals show similar elevations in monoamine neurotransmitters (dopamine, norepinephrine, serotonin), the same neurotransmitters that regulate pleasure, motivation, mood, appetite, sleep, and alertness.

Pain leads to pleasure by triggering the body’s own regulating homeostatic mechanisms. In this case, the initial pain stimulus is followed by gremlins hopping on the pleasure side of the balance. The pleasure we feel is our body’s natural and reflexive physiological response to pain.

With intermittent exposure to pain, our natural hedonic set point gets weighted to the side of pleasure, such that we become less vulnerable to pain and more able to feel pleasure over time.

Socrates (as recorded by Plato in “Socrates’ Reasons for Not Fearing Death”) mused on the relationship between pain and pleasure more than two thousand years ago: How strange would appear to be this thing that men call pleasure! And how curiously it is related to what is thought to be its opposite, pain!

We’ve all experienced some version of pain giving way to pleasure. Perhaps like Socrates, you’ve noticed an improved mood after a period of being ill, or felt a runner’s high after exercise, or took inexplicable pleasure in a scary movie. Just as pain is the price we pay for pleasure, so too is pleasure our reward for pain.

Hormesis is a branch of science that studies the beneficial effects of administering small to moderate doses of noxious and / or painful stimuli, such as cold, heat, gravitational changes, radiation, food restriction, and exercise. Hormesis comes from the ancient Greek hormáein: to set in motion, impel, urge on.

Exercise increases many of the neurotransmitters involved in positive mood regulation: dopamine, serotonin, norepinephrine, epinephrine, endocannabinoids, and endogenous opioid peptides (endorphins).

Dopamine’s ancient role in physical movement relates to its role in motivation: To obtain the object of our desire, we need to go get it.

Exercise has a more profound and sustained positive effect on mood, anxiety, cognition, energy, and sleep than any pill I can prescribe.

We have to remember that we will feel pleasure after pain, and we’re remarkably amnestic about this sort of thing.

Pursuing pain instead of pleasure is also countercultural, going against all the feel-good messages that pervade so many aspects of modern life.

The intentional application of pain to treat pain has been around since at least Hippocrates, who wrote in his Aphorisms in 400 BC: “Of two pains occurring together, not in the same part of the body, the stronger weakens the other.”

With the advent of pharmacotherapy, pain to treat pain came to be seen as a kind of quackery.

Electricity applied to the brain to treat mental illness has been practiced since the early 1900s. In April 1938, Ugo Cerletti and Lucino Bini performed the first electroconvulsive shock therapy (ECT) treatment. ECT is still practiced today to good effect, although much more humanely.

Alex Honnold, now world-famous for climbing the face of Yosemite’s El Capitan without ropes, was found to have below-normal amygdala activation during brain imaging. The researchers who studied Honnold’s brain speculated that he was born with less innate fear than others, which in turn allowed him, they hypothesized, to accomplish superhuman climbing feats. But Honnold himself disagreed with their interpretation: “I’ve done so much soloing, and worked on my climbing skills so much that my comfort zone is quite large. So these things that I’m doing that look pretty outrageous, to me they seem normal.”

Pain to treat pain. Anxiety to treat anxiety. This approach is counterintuitive, and exactly opposite to what we’ve been taught over the last 150 years about how to manage disease, distress, and discomfort.

Extreme sports — skydiving , kitesurfing, hang gliding, bob-sledding, downhill skiing/snowboarding, waterfall kayaking, ice climbing, mountain biking, canyon swinging, bungee jumping, base jumping, wingsuit flying — slam down hard and fast on the pain side of the pleasure-pain balance. Intense pain/fear plus a shot of adrenaline creates a potent drug. Scientists have shown that stress alone can increase the release of dopamine in the brain’s reward pathway, leading to the same brain changes seen with addictive drugs like cocaine and methamphetamine. Just as we become tolerant to pleasure stimuli with repeated exposure, so too can we become tolerant to painful stimuli, resetting our brains to the side of pain.

Technology has allowed us to push the limits of human pain.

“Overtraining syndrome” is a well-described but poorly understood condition among endurance athletes who train so much that they reach a point where exercise no longer produces the endorphins that were once so plentiful. Instead, exercise leaves them feeling depleted and dysphoric, as if their reward balance has maxed out and stopped working.

Too much pain, or in too potent a form, can increase the risk of becoming addicted to pain.

The “workaholic” is a celebrated member of society.

By 2002, the top-paid 20 percent were twice as likely to work long hours as the lowest-paid 20 percent, and that trend continues. Economists speculate that this change is due to higher rewards for those at the top of the economic food chain.

If we consume too much pain, or in too potent a form, we run the risk of compulsive, destructive overconsumption. But if we consume just the right amount, “inhibiting great pain with little pain,” we discover the path to hormetic healing, and maybe even the occasional “fit of joy.”

Radical Honesty

Let’s first establish that telling the truth is painful. We’re wired from the earliest ages to lie, and we all do it, whether or not we care to admit it. Children begin lying as early as age two.

The average adult tells between 0.59 and 1.56 lies daily. Liar, liar, pants on fire.

Humans are not the only animals with the capacity for deception.

The Lying Habit is remarkably easy to fall into. We all engage in regular lying, most of the time without realizing it. Our lies are so small and imperceptible that we convince ourselves we’re telling the truth. Or that it doesn’t matter, even if we know we’re lying.

Radical honesty — telling the truth about things large and small, especially when doing so exposes our foibles and entails consequences — is essential not just to recovery from addiction but for all of us trying to live a more balanced life in our reward-saturated ecosystem. It works on many levels. First, radical honesty promotes awareness of our actions. Second, it fosters intimate human connections. Third, it leads to a truthful autobiography, which holds us accountable not just to our present but also to our future selves. Further, telling the truth is contagious, and might even prevent the development of future addiction.

Recounting our experiences gives us mastery over them. This is especially true for behaviors that involve a level of automaticity outside of conscious awareness.

Denial is likely mediated by a disconnect between the reward pathway part of our brain and the higher cortical brain regions that allow us to narrate the events of our lives, appreciate consequences, and plan for the future. Many forms of addiction treatment involve strengthening and renewing connections between these parts of the brain.

Might the practice of telling the truth strengthen activity and excitability in the parts of the brain we use for future planning, emotion regulation, and delayed gratification?”

Telling the truth draws people in, especially when we’re willing to expose our own vulnerabilities.

Intimacy is its own source of dopamine. Oxytocin, a hormone much involved with falling in love, mother-child bonding, and lifetime pair bonding of sexual mates, binds to receptors on the dopamine-secreting neurons in the brain’s reward pathway and enhances the firing of the reward-circuit tract.

In more than twenty years as a psychiatrist listening to tens of thousands of patient stories, I have become convinced that the way we tell our personal stories is a marker and predictor of mental health.

The victim narrative reflects a wider societal trend in which we’re all prone to seeing ourselves as the victims of circumstance and deserving of compensation or reward for our suffering.

The psychoanalyst Donald Winnicott introduced the concept of “the false self” in the 1960s. According to Winnicott, the false self is a self-constructed persona in defense against intolerable external demands and stressors. Winnicott postulated that the creation of the false self can lead to feelings of profound emptiness. Social media has contributed to the problem of the false self by making it far easier for us, and even encouraging us, to curate narratives of our lives that are far from reality.

When our lived experience diverges from our projected image, we are prone to feel detached and unreal, as fake as the false images we’ve created. Psychiatrists call this feeling de-realization and depersonalization.

The antidote to the false self is the authentic self. Radical honesty is a way to get there.

Why when adults keep their promises to children, those children are better able to regulate their impulses? The way I understand this is by differentiating what I call the plenty versus the scarcity mindset. Truth-telling engenders a plenty mindset. Lying engenders a scarcity mindset.

When the people around us are reliable and tell us the truth, including keeping promises they’ve made to us, we feel more confident about the world and our own future in it. Even in the midst of scarcity, we feel confident that things will turn out okay. This is a plenty mindset.

When the people around us lie and don’t keep their promises, we feel less confident about the future. We go into competitive survival mode and favor short-term gains over long-term ones, independent of actual material wealth. This is a scarcity mindset.

It makes intuitive sense that when resources are scarce, people are more invested in immediate gains, and are less confident that those rewards will still be forthcoming in some distant future.

Having too much material wealth can be as bad as having too little. Dopamine overload impairs our ability to delay gratification.

Prosocial Shame

The psychological literature today identifies shame as an emotion distinct from guilt. The thinking goes like this: Shame makes us feel bad about ourselves as people, whereas guilt makes us feel bad about our actions while preserving a positive sense of self. Shame is a maladaptive emotion. Guilt is an adaptive emotion.

My problem with the shame-guilt dichotomy is that experientially, shame and guilt are identical.

Yet the shame-guilt dichotomy is tapping into something real. I believe the difference is not how we experience the emotion, but how others respond to our transgression.

If others respond by rejecting, condemning, or shunning us, we enter the cycle of what I call destructive shame.

If others respond by holding us closer and providing clear guidance for redemption/recovery, we enter the cycle of prosocial shame. Prosocial shame mitigates the emotional experience of shame and helps us stop or reduce the shameful behavior.

To truly understand someone is to care for them.

Studies show that people who are actively involved in religious organizations on average have lower rates of drug and alcohol misuse. But when faith-based organizations end up on the wrong side of the shame equation, by shunning transgressors and/or encouraging a web of secrecy and lies, they contribute to the cycle of destructive shame.

Destructive shame looks like this: Overconsumption leads to shame, which leads to shunning by the group or lying to the group to avoid shunning, both of which result in further isolation, contributing to ongoing consumption as the cycle is perpetuated.

Prosocial shame is predicated on the idea that shame is useful and important for thriving communities. Without shame, society would descend into chaos. Hence, feeling shame for transgressive behaviors is appropriate and good.

The prosocial shame cycle goes like this: Overconsumption leads to shame, which demands radical honesty and leads not to shunning, as we saw with destructive shame, but to acceptance and empathy, coupled with a set of required actions to make amends. The result is increased belonging and decreased consumption.

Behavioral economists refer to the rewards of belonging to a group as club goods. The more robust the club goods, the more likely the group will be able to maintain its current members and attract new members. The concept of club goods can be applied to any group of humans, from families to friendship groups to religious congregations.

Club goods are threatened by free riders who attempt to benefit from the group without sufficient participation in that community, similar to the more colloquial terms free-loaders or moochers.

Mutual honesty precludes shame and presages an intimacy explosion, a rush of emotional warmth that comes from feeling deeply connected to others when we’re accepted despite our flaws. It is not our perfection but our willingness to work together to remedy our mistakes that creates the intimacy we crave. This kind of intimacy explosion is almost certainly accompanied by the release of our brain’s own endogenous dopamine. But unlike the rush of dopamine we get from cheap pleasures, the rush we get from true intimacy is adaptive, rejuvenating, and health-promoting.

Conclusion

Lessons of the Balance

Lessons of the Balance

  • The relentless pursuit of pleasure (and avoidance of pain) leads to pain.
  • Recovery begins with abstinence.  
  • Abstinence resets the brain’s reward pathway and with it our capacity to take joy in simpler pleasures.
  • Self-binding creates literal and metacognitive space between desire and consumption, a modern necessity in our dopamine-overloaded world.
  • Medications can restore homeostasis, but consider what we lose by medicating away our pain.
  • Pressing on the pain side resets our balance to the side of pleasure.
  • Beware of getting addicted to pain.
  • Radical honesty promotes awareness, enhances intimacy, and fosters a plenty mindset.
  • Prosocial shame affirms that we belong to the human tribe.
  • Instead of running away from the world, we can find escape by immersing ourselves in it.
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